NUR-230 Exam 2 Questions
Answer: 1 Explanation: 1. The presence of meconium in the amniotic fluid indicates that the fetus may be suffering from asphyxia. Meconium-stained newborns or newborns who have aspirated particulate meconium often have respiratory depression at birth and require resuscitation to establish adequate respiratory effort.
1) The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require which of the following? 1. Initial resuscitation 2. Vigorous stimulation at birth 3. Phototherapy immediately 4. An initial feeding of iron-enriched formula
Answer: 1 Explanation: 1. A low maternal serum alpha-fetoprotein test can indicate trisomy 18 or trisomy 21 (Down syndrome). Many couples abort a fetus that has a genetic abnormality that significantly affects quality of life or has multiple medical problems. Down syndrome is more likely to occur in the fetuses of women over the age of 35 at delivery, but is not limited to this age group.
A 27-year-old married woman is 16 weeks pregnant and has an abnormally low maternal serum alpha-fetoprotein test. Which statement indicates that the couple understands the implications of this test result? 1. "We have decided to have an abortion if this baby has Down syndrome." 2. "If we hadn't had this test, we wouldn't have to worry about this baby." 3. "I'll eat plenty of dark green leafy vegetables until I have the ultrasound." 4. "The ultrasound should be normal because I'm under the age of 35."
Answer: 1 Explanation: 1. Infants of diabetic mothers (IDMs) have a high incidence of false-positive results (i.e., the L/S ratio is thought to indicate lung maturity, but after birth the baby develops RDS).
A 28-year-old woman has been an insulin-dependent diabetic for 10 years. At 36 weeks' gestation, she has an amniocentesis. A lecithin/sphingomyelin (L/S) ratio test is performed on the sample of her amniotic fluid. Because she is a diabetic, what would an obtained 2:1 ratio indicate for the fetus? 1. The fetus may or may not have immature lungs. 2. The amniotic fluid is contaminated. 3. The fetus has a neural tube defect. 4. There is blood in the amniotic fluid.
Answer: 1 Explanation: 1. Extremely premature newborns are particularly susceptible to injury of the delicate capillaries of the retina causing characteristic retinal changes known as retinopathy of prematurity (ROP). Judicious use of supplemental oxygen therapy in the premature infant has become the norm.
A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. Due to oxygen therapy, the nurse explains to the parents, their infant is at a greater risk for which of the following? 1. Visual impairment 2. Hyperthermia 3. Central cyanosis 4. Sensitive gag reflex
Answer: 4 Explanation: 4. Hypothermia is a common complication in the SGA newborn; therefore, the newborn's environment must remain warm, to decrease heat loss.
A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? 1. Monitor for feeding difficulties. 2. Assess for facial paralysis. 3. Monitor for signs of hyperglycemia. 4. Maintain a warm environment.
Answer: 4 Explanation: 4. A blood sugar level of 47 mg/dL is a normal finding; documentation is an appropriate action.
A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dL. What is the best nursing action? 1. To recheck the blood sugar in 6 hours 2. To begin an IV of 10% dextrose 3. To feed the baby 1 ounce of formula 4. To document the findings in the chart
Answer: 2, 3, 5 Explanation: 2. Noise levels can be lowered by replacing alarms with lights or silencing alarms quickly. 3. Dimmer switches should be used to shield the baby's eyes from bright lights with blankets over the top portion of the incubator. 5. Dimming the lights may encourage infants to open their eyes and be more responsive to their parents.
A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU? Select all that apply. 1. Schedule care throughout the day. 2. Silence alarms quickly. 3. Place a blanket over the top portion of the incubator. 4. Do not offer a pacifier. 5. Dim the lights.
Answer: 1 Explanation: 1. A primary danger of general anesthesia is fetal depression. The depression in the fetus is directly proportional to the depth and duration of the anesthesia.
A cesarean section is ordered for a pregnant client. Because the client is to receive general anesthesia, what is the primary danger with which the nurse is concerned? 1. Fetal depression 2. Vomiting 3. Maternal depression 4. Uterine relaxation
Answer: 1, 2, 3 Explanation: 1. A primary danger of general anesthesia is fetal depression, because the medication reaches the fetus in about 2 minutes. The depression is directly proportional to the depth and duration of anesthesia. 2. The poor fetal metabolism of general anesthetic agents is similar to that of analgesic agents administered during labor. General anesthesia is not advocated when the fetus is considered to be at high risk, particularly in preterm birth. 3. Most general anesthetic agents cause some degree of uterine relaxation.
A cesarean section is ordered for the laboring client with whom the nurse has worked all shift. The client will receive general anesthesia. The nurse knows that potential complications of general anesthesia include which of the following? Select all that apply. 1. Fetal depression that is directly proportional to the depth and duration of the anesthesia 2. Poor fetal metabolism of anesthesia, which inhibits use with preterm infants 3. Uterine relaxation 4. Increased gastric motility 5. Itching of the face and neck
Answer: 2 Explanation: 2. In the early or latent phase of the first stage of labor, contractions are usually mild. The woman feels able to cope with the discomfort. The woman is often talkative and smiling and is eager to talk about herself and answer questions.
A client arrives in the labor and delivery unit and describes her contractions as occurring every 10-12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor. On exam, her cervix is dilated 2 cm, 100% effaced, and -2 station. What best describes this labor? 1. Second phase 2. Latent phase 3. Active phase 4. Transition phase
Answer: 4 Explanation: 4. Secretory IgA, an immunoglobulin present in colostrum and mature breast milk, has antiviral, antibacterial, and antigenic-inhibiting properties and plays a role in decreasing the permeability of the small intestine to help prevent large protein molecules from triggering an allergic response.
A client at 20 weeks' gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the client indicate that the teaching was successful? 1. "Formula-feeding gives the baby protection from infections." 2. "Breast milk cannot be stored; it has to be thrown away after pumping." 3. "Breastfeeding is more expensive than formula-feeding." 4. "My baby will have a lower risk of food allergies if I breastfeed."
Answer: 2 Explanation: 2. A negative CST shows three contractions of good quality lasting 40 or more seconds in 10 minutes without evidence of late decelerations. This is the desired result.
A client at 37 weeks' gestation has a mildly elevated blood pressure. Her antenatal testing demonstrates three contractions in 10 minutes, no decelerations, and accelerations four times in 1 hour. What would this test be considered? 1. Positive non-stress test 2. Negative contraction stress test 3. Positive contraction stress test 4. Negative non-stress test
Answer: 2, 4, 5 Explanation: 2. This motion separates the amniotic membranes that are lying against the lower uterine segment and internal os from the distal part of the lower uterine segment. 4. If labor is initiated, it typically begins within 24-48 hours. 5. Uterine contractions, cramping, scant bleeding, and bloody discharge can occur after stripping of the membranes.
A client at 40 weeks' gestation is to undergo stripping of the membranes. The nurse provides the client with information about the procedure. Which information is accurate? Select all that apply. 1. Intravenous administration of oxytocin will be used to initiate contractions. 2. The physician/CNM will insert a gloved finger into the cervical os and rotate the finger 360 degrees. 3. Stripping of the membranes will not cause discomfort, and is usually effective. 4. Labor should begin within 24-48 hours after the procedure. 5. Uterine contractions, cramping, and a bloody discharge can occur after the procedure.
Answer: 1, 2, 3 Explanation: 1. A large fetus places a woman at risk for an episiotomy to prevent lacerations. 2. Use of forceps or vacuum extractor is a risk factor that predisposes women to episiotomies. 3. Shoulder dystocia is a risk factor that predisposes women to episiotomies.
A client attending a prenatal class asks why episiotomies are performed. The nurse explains that risk factors that predispose women to episiotomies include which of the following? Select all that apply. 1. Large or macrosomic fetus 2. Use of forceps 3. Shoulder dystocia 4. Maternal health 5. Shorter second stage
Answer: 2 Explanation: 2. Lightening describes the effect occurring when the fetus begins to settle into the pelvic inlet.
A client calls the labor and delivery unit and tells the nurse that she is 39 weeks pregnant and that over the last 4 or 5 days, she has noticed that although her breathing has become easier, she is having leg cramps, a slight amount of edema in her lower legs, and an increased amount of vaginal secretions. The nurse tells the client that she has experienced which of the following? 1. Engagement 2. Lightening 3. Molding 4. Braxton Hicks contractions
Answer: 3 Explanation: 3. Ephedrine is the medication of choice to increase maternal blood pressure.
A client dilated to 5 cm has just received an epidural for pain. She complains of feeling lightheaded and dizzy within 10 minutes after the procedure. Her blood pressure was 120/80 before the procedure and is now 80/52. In addition to the bolus of fluids she has been given, which medication is preferred to increase her BP? 1. Epinephrine 2. Terbutaline 3. Ephedrine 4. Epifoam
Answer: 1, 3 Explanation: 1. Blood pressure should be monitored every 1 to 2 minutes for the first 10 minutes and then every 5 to 15 minutes until the block wears off because hypotension is the most common side effect of epidural anesthesia. 3. Nursing care following an epidural block includes frequent assessment of the bladder to avoid bladder distention. Catheterization may be necessary, because most women are unable to void.
A client had an epidural inserted 2 hours ago. It is functioning well, the client is stable, and labor is progressing. Which parts of the nurse's assessment have the highest priority? Select all that apply. 1. Assess blood pressure every hour. 2. Assess the pulse rate every hour. 3. Palpate the bladder. 4. Auscultate the lungs. 5. Assess the reflexes.
Answer: 2, 3 Explanation: 2. Fetal heart rate auscultation gives information about the physical status of the fetus. 3. Contraction palpation provides information about the frequency, duration, and intensity of the contractions.
A client has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus? Select all that apply. 1. Check for ruptured membranes and apply a fetal scalp electrode. 2. Auscultate the fetal heart rate between and during contractions. 3. Palpate contractions and resting uterine tone. 4. Assess the blood pressure, temperature, respiratory rate, and pulse rate. 5. Perform a vaginal exam for cervical dilation, and perform Leopold maneuvers.
Answer: 2 Explanation: 2. If the infant has absent or depressed respirations, heart rate less than 100 beats/min, or poor muscle tone, direct tracheal suctioning by specially trained personnel is recommended.
A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse anticipate? 1. Delivery of the neonate on its side with head up, to facilitate drainage of secretions. 2. Direct tracheal suctioning by specially trained personnel. 3. Preparation for the immediate use of positive pressure to expand the lungs. 4. Suctioning of the oropharynx when the newborn's head is delivered.
Answer: 3 Explanation: 3. The transition phase begins with 8 cm to 10 cm of dilatation, and contractions become more frequent, are longer in duration, and increase in intensity.
A client is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier that morning. A vaginal exam reveals that her cervix is 100 percent effaced and 8 cm dilated. The nurse knows that the client is in which phase of labor? 1. Active 2. Latent 3. Transition 4. Fourth
Answer: 3 Explanation: 3. The transition phase begins with 8 cm of dilatation, and is characterized by contractions that are closer and more intense.
A client is admitted to the labor and delivery unit with contractions that are regular, are 2 minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8 cm dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of labor? 1. Latent phase 2. Active phase 3. Transition phase 4. Fourth stage
Answer: 2 Explanation: 2. During transition, contractions have a frequency of 1 1/2 to 2 minutes, a duration of 60 to 90 seconds, and are strong in intensity. When the woman enters the transition phase, she may demonstrate significant anxiety.
A client is admitted to the labor unit with contractions 1-2 minutes apart lasting 60-90 seconds. The client is apprehensive and irritable. This client is most likely in what phase of labor? 1. Active 2. Transition 3. Latent 4. Second
Answer: 3 Explanation: 3. Women whose previous cesarean was performed because of nonrecurring indications have been reported to have approximately a 60% to 80% chance of success with VBAC.
A client is consulting a certified nurse-midwife because she is hoping for a vaginal birth after cesarean (VBAC) with this pregnancy. Which statement indicates that the client requires more information about VBAC? 1. "I can try a vaginal birth because my uterine incision is a low segment transverse incision." 2. "The vertical scar on my skin doesn't mean that the scar on my uterus goes in the same direction." 3. "There is about a 90% chance of giving birth vaginally after a cesarean." 4. "Because my hospital has a surgery staff on call 24 hours a day, I can try a VBAC there."
Answer: 2 Explanation: 2. Nursing care following an epidural block includes frequent assessment of the bladder to avoid bladder distention.
A client received epidural anesthesia during the first stage of labor. The epidural is discontinued immediately after delivery. This client is at increased risk for which problem during the fourth stage of labor? 1. Nausea 2. Bladder distention 3. Uterine atony 4. Hypertension
Answer: 1, 4, 5 Explanation: 1. True labor contractions intensify while walking. 4. True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen. 5. In true labor, contractions do not lessen with rest and warm tub baths.
A client who is having false labor most likely would have which of the following? Select all that apply. 1. Contractions that do not intensify while walking 2. An increase in the intensity and frequency of contractions 3. Progressive cervical effacement and dilatation 4. Pain in the abdomen that does not radiate 5. Contractions that lessen with rest and warm tub baths
Answer: 1, 4 Explanation: 1. In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely. 4. In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely.
A clinic nurse is preparing diagrams of pelvic shapes. Which pelvic shapes are considered least adequate for vaginal childbirth? Select all that apply. 1. Android 2. Anthropoid 3. Gynecoid 4. Platypelloid 5. Lambdoidal suture
Answer: 1, 3, 5 Explanation: 1. A Fear/Anxiety diagnosis would apply to the first stage of labor for a first-time labor client. 3. Contractions become more regular in frequency and duration, increasing discomfort and pain. 5. The woman and her boyfriend are about to undergo one of the most meaningful and stressful events in life together. Physical and psychologic resources, coping mechanisms, and support systems will all be challenged.
A first-time 22-year-old single labor client, accompanied by her boyfriend, is admitted to the labor unit with ruptured membranes and mild to moderate contractions. She is determined to be 2 centimeters dilated. Which nursing diagnoses might apply during the current stage of labor? Select all that apply. 1. Fear/Anxiety related to discomfort of labor and unknown labor outcome 2. Knowledge, Deficient, related to lack of information about pushing methods 3. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent 4. Pain, Acute, related to perineal trauma 5. Coping: Family, Compromised, related to labor process
Answer: 3 Explanation: 3. The IUPC has several benefits over an external tocotransducer or palpation. Because the IUPC is inserted directly into the uterus, it provides near-exact pressure measurements for contraction intensity and uterine resting tone. The increased sensitivity of the IUPC allows for very accurate timing of uterine contractions (UCs).
A laboring client asks the nurse, "Why does the physician want to use an intrauterine pressure catheter (IUPC) during my labor?" The nurse would accurately explain that the best rationale for using an IUPC is which of the following? 1. The IUPC can be used throughout the birth process. 2. A tocodynamometer is invasive. 3. The IUPC provides more accurate data than does the tocodynamometer. 4. The tocodynamometer can be used only after the cervix is dilated 2 cm.
Answer: 2 Explanation: 2. The risk of hypotension can be minimized by hydrating the vascular system with 500 to 1000 mL of IV solution before the procedure and changing the woman's position and/or increasing the IV rate afterward.
A laboring client has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, what would the nurse expect to do? 1. Observe fetal heart rate variability 2. Hydrate the vascular system with 500-1000 mL of intravenous fluids 3. Place the client in the semi-Fowler's position 4. Teach the client appropriate breathing techniques
Answer: 1 Explanation: 1. Contractions after amniotomy are similar to those of spontaneous labor.
A laboring client's obstetrician has suggested amniotomy as a method for creating stronger contractions and facilitating birth. The client asks, "What are the advantages of doing this?" What should the nurse cite in response? 1. Contractions elicited are similar to those of spontaneous labor. 2. Amniotomy decreases the chances of a prolapsed cord. 3. Amniotomy reduces the pain of labor and makes it easier to manage. 4. The client will not need an episiotomy.
Answer: 3 Explanation: 3. Before an amniotomy is performed, the fetus is assessed for presentation, position, station, and FHR.
A laboring client's obstetrician has suggested amniotomy as a method for inducing labor. Which assessment(s) must be made just before the amniotomy is performed? 1. Maternal temperature, BP, and pulse 2. Estimation of fetal birth weight 3. Fetal presentation, position, and station 4. Biparietal diameter
Answer: 3 Explanation: 3. Most newborns can be effectively resuscitated by bag-and-mask ventilation.
A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best? 1. Begin chest compressions. 2. Begin direct tracheal suctioning. 3. Begin bag-and-mask ventilation. 4. Obtain a blood pressure reading.
Answer: 1, 5 Explanation: 1. The newborn should be placed on his or her back (supine) for sleeping. 5. During the first few days of life, the newborn has increased mucus, and gentle suctioning with a bulb syringe may be indicated.
A mother and her newborn are being discharged 2 days after delivery. The general discharge instructions provided by the nurse include which of the following? Select all that apply. 1. Always place the infant in a supine position in the crib. 2. Support the infant's head when carrying for the first week or two. 3. Do not allow the baby to fall asleep in someone's arms. 4. Cover the cord stump with a bandage. 5. Use a bulb syringe to suction mucus from the infant's nostrils as necessary.
Answer: 2 Explanation: 2. For infants, AZT is started prophylactically 2 mg/kg/dose PO every 6 hours beginning as soon after birth as possible and continuing for 6 weeks.
A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant? 1. Test with a HIV serologic test at 8 months. 2. Begin prophylactic AZT (Zidovudine) administration. 3. Provide 4 to 5 large feedings throughout the day. 4. Encourage the mother to breastfeed the child.
Answer: 1, 2, 5 Explanation: 1. Secretory IgA, an immunoglobulin present in colostrum and mature breast milk, has antiviral, antibacterial, and antigenic-inhibiting properties. 2. Early breastfeeding can enhance maternal-infant bonding. 5. The mother's sense of accomplishment in being able to satisfy her baby's needs for nourishment and comfort can be a tremendous source of personal satisfaction.
A new mother is questioning the nurse about the advantages of breastfeeding her newborn. Which information should the nurse include in the teaching session? Select all that apply. 1. Breast milk has immunological advantages, including varying degrees of protection from bacterial and viral infections. 2. Breastfeeding has been shown to increase maternal-infant attachment. 3. Breastfeeding can be initially supplemented with bottle feedings so that the father does not feel left out of the infant's care. 4. Breastfeeding often causes nipple tenderness, and may be discouraged until healing occurs. 5. Breastfeeding provides a psychologic advantage to the mother, who derives satisfaction knowing that she is providing her infant with the optimal nutritional start in life.
Answer: 2 Explanation: 2. Breastfeeding babies may not be allergic to the mother's milk but rather to the cow's milk protein (an antigen) in the mother's milk. By eliminating the culprit (e.g., the bovine protein) from the mother's diet and therefore from the breast milk, the mother can continue to breastfeed, providing optimal nutrition and immune factors to her infant.
A new mother who is breastfeeding tells the nurse that her infant is spitting up frequently, has very loose stools and copious gas, and feeds for only short periods of time. The nurse suspects a feeding intolerance and, after questioning the mother about her diet, suggests that she do which of the following? 1. Stop breastfeeding and switch to formula. 2. Eliminate dairy products from her diet. 3. Supplement breastfeeding with a soy-based formula. 4. Offer the baby water between feedings.
Answer: 1 Explanation: 1. Cool baths will chill a newborn, and should not be given. Bathing under warm water is ideal.
A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following? 1. "A quick cool bath will help wake up my son for feedings." 2. "I can check my son's temperature under his arm." 3. "My baby should be dressed warmly, with a hat." 4. "Cuddling my son will help to keep him warm."
Answer: 4 Explanation: 4. Infants undergoing phototherapy treatment have increased water loss and loose stools as a result of bilirubin excretion. This increases their risk of dehydration.
A newborn is receiving phototherapy. Which intervention by the nurse would be most important? 1. Measurement of head circumference 2. Encouraging the mother to stop breastfeeding 3. Stool blood testing 4. Assessment of hydration status
Answer: 3 Explanation: 3. A respiratory rate of 40 during sleep is normal.
A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following signs and symptoms would not be characteristic of RDS? 1. Grunting respirations 2. Nasal flaring 3. Respiratory rate of 40 during sleep 4. Chest retractions
Answer: 4 Explanation: 4. In babies with respiratory distress syndrome (RDS) who are on ventilators, increased urination/diuresis may be an early clue that the baby's condition is improving.
A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment? 1. Decreased urine output 2. Pulmonary vascular resistance increases 3. Increased PCO2 4. Increased urination
Answer: 1 Explanation: 1. Following the birth, the woman may be kept flat. Although the effectiveness of the supine position to avoid headache following a spinal is controversial, the physician's orders may include lying flat for 6 to 12 hours.
A nurse is checking the postpartum orders. The doctor has prescribed bed rest for 6-12 hours. The nurse knows this is an appropriate order if the client had which type of anesthesia? 1. Spinal 2. Pudendal 3. General 4. Epidural
Answer: 2 Explanation: 2. The mother may continue to breastfeed, but the caregiver may choose to prescribe additional vitamins for the newborn. Vitamins in human milk are influenced by the mother's vitamin intake, general nutritional status, and genetic differences.
A nurse is evaluating the diet plan of a breastfeeding mother, and determines that her intake of fruits and vegetables is inadequate. The nurse explains that the nutritional composition of the mother's breast milk can be adversely affected by this nutritional inadequacy. Which strategy should the nurse recommend to the mother? 1. Stop breastfeeding 2. Provide newborn supplements to the newborn 3. Offer whole milk 4. Supplement with skim milk
Answer: 2 Explanation: 2. Often fussy breastfeeding or cow's milk-based formula-fed infants are switched to a lactose-free formula because of concerns about lactose intolerance.
A nurse is evaluating the diet plan of a breastfeeding mother. Which beverage is most likely to cause intolerance in the infant? 1. Orange juice 2. Milk 3. Decaffeinated tea 4. Water
Answer: 1, 3, 4 Explanation: 1. The nurse would remove the needle and massage the site with an alcohol swab. 3. Vitamin K is given intramuscularly in the vastus lateralis muscle. 4. Before injecting, the nurse must clean the newborn's skin site for the injection thoroughly with a small alcohol swab.
A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Select all that apply. 1. Gently massage the site after injection. 2. Use a 22-gauge, 1-inch needle. 3. Inject in the vastus lateralis muscle. 4. Cleanse the site with alcohol prior to injection. 5. Inject at a 45-degree angle.
Answer: 1 Explanation: 1. Cervical dilatation of 6 cm indicates the active phase of labor. During this phase the cervix dilates from about 4 to 7 cm and contractions and pain intensify.
A nurse needs to evaluate the progress of a woman's labor. The nurse obtains the following data: cervical dilatation 6 cm; contractions mild in intensity, occurring every 5 minutes, with a duration of 30-40 seconds. Which clue in this data does not fit the pattern suggested by the rest of the clues? 1. Cervical dilatation 6 cm 2. Mild contraction intensity 3. Contraction frequency every 5 minutes 4. Contraction duration 30-40 seconds
Answer: 1 Explanation: 1. The site should be cleaned by rubbing vigorously with 70% isopropyl alcohol swab. The friction produces local heat, which aids vasodilation.
A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, what does the nursing instructor tell the student do? 1. Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood. 2. Use a previous puncture site. 3. Cool the heel prior to obtaining blood. 4. Use a sterile needle and aspirate.
Answer: 1 Explanation: 1. Parents should check cord each day for any odor, oozing of greenish yellow material, or reddened areas around the cord. They should report to healthcare provider any signs of infection.
A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurse's best response? 1. "Take your newborn to the pediatrician." 2. "Cover the cord stump with gauze." 3. "Apply Betadine around the cord stump." 4. "This is normal during healing."
Answer: 2 Explanation: 2. The first voiding should occur within 24 hours and first passage of stool within 48 hours.
A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurse's best response? 1. "I will call your pediatrician immediately." 2. "Passage of the first stool within 48 hours is normal." 3. "Your newborn might not have a stool until the third day." 4. "Your newborn must be dehydrated."
Answer: 4 Explanation: 4. Hyperstimulation is characterized by contractions that occur more frequently than every 2 minutes or last longer than 90 seconds.
A pregnant woman is having a nipple-stimulated contraction stress test. Which result indicates hyperstimulation? 1. The fetal heart rate decelerates when three contractions occur within a 10-minute period. 2. The fetal heart rate accelerates when contractions last up to 60 seconds. 3. There are more than five fetal movements in a 10-minute period. 4. There are more than three uterine contractions in a 6-minute period.
Answer: 1, 2, 3, 5 Explanation: 1. When the placenta completely covers the uterine opening, a cesarean is performed. 2. Premature separation of the placenta from the uterine wall requires an immediate cesarean. 3. A prolapsed cord is an emergency requiring an immediate cesarean. 5. Failure to progress in labor can necessitate a cesarean birth.
A prenatal client asks the nurse about conditions that would necessitate a cesarean delivery. The nurse explains that cesarean delivery generally is performed in the presence of which of the following? Select all that apply. 1. Complete placenta previa 2. Placental abruption 3. Umbilical cord prolapse 4. Precipitous labor 5. Failure to progress
Answer: 3, 4, 5 Explanation: 3. A standard ultrasound examination is performed during the second or third trimester and includes an evaluation to determine fetal presentation. 4. A standard ultrasound examination is performed during the second or third trimester and includes an evaluation of amniotic fluid volume. 5. A standard ultrasound examination is performed during the second or third trimester and includes an evaluation of fetal number.
A standard ultrasound examination is performed during the second or third trimester and includes an evaluation of which of the following? Select all that apply. 1. Confirm fetal heart activity. 2. Evaluate the cervix. 3. Determine fetal presentation. 4. Amniotic fluid volume. 5. Fetal number.
Answer: 4 Explanation: 4. Lack of fetal activity for 30 minutes typically is insignificant. Movement varies considerably, but most women feel fetal movement at least 10 times in 3 hours.
A woman at 28 weeks' gestation is asked to keep a fetal activity record and to bring the results with her to her next clinic visit. One week later, she calls the clinic and anxiously tells the nurse that she has not felt the baby move for more than 30 minutes. Which of the following would be the nurse's most appropriate initial comment? 1. "You need to come to the clinic right away for further evaluation." 2. "Have you been smoking?" 3. "When did you eat last?" 4. "Your baby might be asleep."
Answer: 2 Explanation: 2. Terbutaline is administered to achieve uterine relaxation.
A woman has been admitted for an external version. She has completed an ultrasound exam and is attached to the fetal monitor. Prior to the procedure, why will terbutaline be administered? 1. To provide analgesia 2. To relax the uterus 3. To induce labor 4. To prevent hemorrhage
Answer: 2 Explanation: 2. Baseline variability is a reliable indicator of fetal cardiac and neurologic function and well-being. The opposing "push-pull" balancing between the sympathetic nervous system and the parasympathetic nervous system directly affects the FHR.
A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching? 1. "The most important part of fetal heart monitoring is the absence of variable decelerations." 2. "The most important part of fetal heart monitoring is the presence of variability." 3. "The most important part of fetal heart monitoring is the fetal heart rate baseline." 4. "The most important part of fetal heart monitoring is the depth of decelerations."
Answer: 4 Explanation: 4. Meconium-stained amniotic fluid is an abnormal fetal finding, and is an indication for continuous fetal monitoring.
A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately? 1. Change the client's position in bed. 2. Notify the physician that birth is imminent. 3. Administer oxygen at 2 liters per minute. 4. Begin continuous fetal heart rate monitoring.
Answer: 3, 4, 5 Explanation: 3. An abnormal fetal heart rate or tracing would be a contraindication to performing a version. A nonreassuring FHR pattern might indicate that the fetus is already stressed and other action needs to be taken. 4. A previous cesarean is a contraindication for version. 5. Rupture of membranes is a contraindication for version because of insufficient amniotic fluid.
A woman is scheduled to have an external version for a breech presentation. The nurse carefully reviews the client's chart for contraindications to this procedure, including which of the following? Select all that apply. 1. Station -2 2. 38 weeks' gestation 3. Abnormal fetal heart rate and tracing 4. Previous cesarean section 5. Rupture of membranes
Answer: 4, 5 Explanation: 4. This is a sign of true labor. The contractions increase in duration and intensity and begin in the back and radiate around to the abdomen. 5. It is a sign of true labor when the client is unable to walk during the contraction.
A woman who is 40 weeks pregnant calls the labor suite to ask whether she should be evaluated. Which statements by the client indicate she is likely in labor? Select all that apply. 1. "The contractions are 5-20 minutes apart." 2. "I had pink discharge on the toilet paper." 3. "I have had cramping for the past 3-4 hours." 4. "The contractions start in my back and then go to my abdomen and are very intense." 5. "The contractions hurt more when I walk."
2
APGAR Activity Flexed arms & legs that resist extension
0
APGAR Activity None
1
APGAR Activity Some flexion
0
APGAR Appearance Blue or pale all over
2
APGAR Appearance Body & extremities pink NO cyanosis
1
APGAR Appearance Body pink Blue at extremities "acrocyanosis"
Appearance Pulse Grimace Activity Respirations
APGAR Categories
2
APGAR Grimace (reflex, irritability) Cry on stimulation
1
APGAR Grimace (reflex, irritability) Grimace on suction or aggressive stimulation
0
APGAR Grimace (reflex, irritability) No response to stimulation
1
APGAR Pulse <100/min
2
APGAR Pulse >100/min
0
APGAR Pulse Absent
0
APGAR Respirations Absent
2
APGAR Respirations Strong, Robust Cry
1
APGAR Respirations Weak, Irregular, Gasping
Answer: 1 Explanation: 1. The most common complication of an epidural is maternal hypotension.
After administration of an epidural anesthetic to a client in active labor, it is most important to assess the mother immediately for which of the following? 1. Hypotension 2. Headache 3. Urinary retention 4. Bradycardia
Answer: 1 Explanation: 1. The transverse incision is made across the lowest and narrowest part of the abdomen and is the most common lower uterine segment incision.
After being in labor for several hours with no progress, a client is diagnosed with CPD (cephalopelvic disproportion), and must have a cesarean section. The client is worried that she will not be able to have any future children vaginally. After sharing this information with her care provider, the nurse would anticipate that the client would receive what type of incision? 1. Transverse 2. Infraumbilical midline 3. Classic 4. Vertical
Answer: 4 Explanation: 4. After the gel, intravaginal insert, or tablet is inserted, the woman is instructed to remain lying down with a rolled blanket or hip wedge under her right hip to tip the uterus slightly to the left for the first 30 to 60 minutes to maintain the cervical ripening agent in place.
After inserting prostaglandin gel for cervical ripening, what should the nurse do? 1. Apply an internal fetal monitor. 2. Insert an indwelling catheter. 3. Withhold oral intake and start intravenous fluids. 4. Place the client in a supine position with a right hip wedge.
Answer: 3 Explanation: 3. Narcan is useful for respiratory depression caused by nalbuphine (Nubain). Respiratory depression in the mother or fetus/newborn can be improved by the administration of naloxone (Narcan), which is a specific antagonist for this agent.
After nalbuphine hydrochloride (Nubain) is administered, labor progresses rapidly, and the baby is born less than 1 hour later. The baby shows signs of respiratory depression. Which medication should the nurse be prepared to administer to the newborn? 1. Fentanyl (Sublimaze) 2. Butorphanol tartrate (Stadol) 3. Naloxone (Narcan) 4. Pentobarbital (Nembutal)
Answer: 3 Explanation: 3. Meconium-stained fluid and heart rate decelerations are indications that delivery is considered higher-risk.
After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what? 1. Increase the mother's oxygen rate. 2. Turn the mother to the left lateral position. 3. Prepare the mother for a higher-risk delivery. 4. Increase the intravenous infusion rate.
Answer: 4 Explanation: 4. Variable decelerations occur when there is umbilical cord compression.
After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? 1. Breech presentation 2. Uteroplacental insufficiency 3. Compression of the fetal head 4. Umbilical cord compression
Answer: 2, 4, 5 Explanation: 2. There is usually no risk of hypertonus or rupture of the uterus and this is an advantage of amniotomy. 4. The color and composition of amniotic fluid can be evaluated and this is an advantage of amniotomy. 5. The contractions elicited are similar to those of spontaneous labor and this is an advantage of amniotomy.
Amniotomy as a method of labor induction has which of the following advantages? Select all that apply. 1. The danger of a prolapsed cord is decreased. 2. There is usually no risk of hypertonus or rupture of the uterus. 3. The intervention can cause a decrease in pain. 4. The color and composition of amniotic fluid can be evaluated. 5. The contractions elicited are similar to those of spontaneous labor.
Answer: 2 Explanation: 2. The nurse should instruct the parents about proper hand-washing techniques, about proper disposal of soiled diapers, and to wear gloves when diapering.
An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care for the newborn at home. Which instructions should the nurse include? 1. Do not add food supplements to the baby's diet. 2. Place soiled diapers in a sealed plastic bag. 3. Wash soiled linens in cool water with bleach. 4. Shield the baby's eyes from bright lights.
Answer: 2, 5 Explanation: 2. Contraindications for epidural block include patients with previous back surgery. 5. Contraindications for epidural block include patients with previous back surgery.
An anesthesiologist informs the nurse that a client scheduled for a caesarean section will be having general anesthesia with postoperative self-controlled analgesia. For which clients would a general anesthesia be recommended? Select all that apply. 1. The client with a history of hypertension 2. The client who has had a lower back fusion 3. The client who is 13 years old 4. The client who is allergic to morphine sulfate 5. The client who has had surgery for scoliosis
Answer: 1, 3, 4, 5 Explanation: 1. The nurse will assist in obtaining skin cultures. Skin cultures are taken of any lesions or drainage from lesions or reddened areas. 3. The nurse will observe for hyperbilirubinemia, anemia, and hemorrhagic symptoms. 4. The nurse will administer oxygen as ordered. 5. The nurse will observe for signs of hypoglycemia.
Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Select all that apply. 1. Obtain skin cultures. 2. Restrict parental visits. 3. Evaluate bilirubin levels. 4. Administer oxygen as ordered. 5. Observe for signs of hypoglycemia.
Answer: 1 Explanation: 1. After administration, the nurse massages the eyelid gently to distribute the ointment.
Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin) include which of the following? 1. Massaging eyelids gently following application 2. Irrigating eyes after instillation 3. Using a syringe to apply ointment 4. Instillation is in the upper conjunctival surface of each eye
Answer: 1 Explanation: 1. The purpose of the non-stress test is to determine the results of movement on fetal heart rate. The NST is typically performed with the woman in the semi-Fowler's position with a small pillow or blanket under the right hip to displace the uterus to the left.
At 32 weeks' gestation, a woman is scheduled for a second non-stress test (following one she had at 28 weeks' gestation). Which statement by the client would indicate an adequate understanding of this procedure? 1. "I can't get up and walk around during the test." 2. "I'll have an IV started before the test." 3. "I can still smoke before the test." 4. "I need to have a full bladder for this test."
Answer: 2 Explanation: 2. This newborn's weight loss is within normal limits. A weight loss of up to 10% for term newborns is considered within normal limits during the first week of life.
At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborn's weight is which of the following? 1. Excessive 2. Within normal limits 3. Less than expected 4. Unusual
Answer: 1, 3 Explanation: 1. The woman should have recently emptied her bladder before performing Leopold maneuvers. 3. The woman should lie on her back with her abdomen uncovered. To aid in relaxation of the abdominal wall, the shoulders should be raised slightly on a pillow and the knees drawn up a little.
Before performing Leopold maneuvers, what would the nurse do? Select all that apply. 1. Have the client empty her bladder. 2. Place the client in Trendelenburg position. 3. Have the client lie on her back with her feet on the bed and knees bent. 4. Turn the client to her left side. 5. Have the client lie flat with her ankles crossed.
Answer: 4 Explanation: 4. Newborn screening tests include hearing screening tests.
Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following? 1. Preeclampsia screening 2. Congenital kidney disease screening 3. Visual screening 4. Hearing screening
Answer: 2, 4, 5 Explanation: 2. Stabilization of vital signs is a benefit of skin-to-skin care as a developmental intervention. 4. Decline in the episodes of apnea and bradycardia is a benefit of skin-to-skin care as a developmental intervention. 5. Increased growth parameters are a benefit of skin-to-skin care as a developmental intervention.
Benefits of skin-to-skin care as a developmental intervention include which of the following? Select all that apply. 1. Routine discharge 2. Stabilization of vital signs 3. Increased periods of awake-alert state 4. Decline in the episodes of apnea and bradycardia 5. Increased growth parameters
Answer: 1, 2, 3, 5 Explanation: 1. Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. 2. Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. 3. Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. 5. Childbirth preparation offers several advantages. Each method has been shown to shorten labor.
Childbirth preparation offers several advantages including which of the following? Select all that apply. 1. It helps a pregnant woman and her support person understand the choices in the birth setting. 2. It promotes awareness of available options. 3. It provides tools for a pregnant woman and her support person to use during labor and birth. 4. Women who receive continuous support during labor require more analgesia, and have more cesarean and instrument births. 5. Each method has been shown to shorten labor.
Duncan presentation: "Dirty Duncan" - more likely to hemorrhage
Dull maternal surface of placenta emerges first
Answer: 4 Explanation: 4. The fetal heart rate (FHR) is heard most clearly at the fetal back. Thus, in a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen.
During a maternal assessment, the nurse determines the fetus to be in a left occiput anterior (LOA) position. Auscultation of the fetal heart rate should begin in what quadrant? 1. Right upper quadrant 2. Left upper quadrant 3. Right lower quadrant 4. Left lower quadrant
Answer: 3 Explanation: 3. The FHR acceleration must be at least 15 beats per minute above baseline for at least 15 seconds from baseline to baseline. A nonreactive NST is one that lacks sufficient FHR accelerations over a 40-minute period.
During a non-stress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test, and last 20 seconds each. The nurse realizes these results will be interpreted as which of the following? 1. A negative test 2. A reactive test 3. A nonreactive test 4. An equivocal test
Answer: 1, 2, 3, 5 Explanation: 1. Amniotomy is the artificial rupture of the amniotic membranes and can be used to induce labor. 2. Amniotomy can be done to augment labor. 3. Amniotomy allows access to the fetus in order to apply an internal fetal electrode to the fetal scalp. 5. Amniotomy may be performed during labor to allow an intrauterine pressure catheter to be inserted.
During a visit to the obstetrician, a pregnant client questions the nurse about the potential need for an amniotomy. The nurse explains that an amniotomy is performed to do which of the following? Select all that apply. 1. Stimulate the beginning of labor 2. Augment labor progression 3. Allow application of an internal fetal electrode 4. Allow application of an external fetal monitor 5. Allow insertion of an intrauterine pressure catheter
Answer: 3 Explanation: 3. Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoring should be implemented.
During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following? 1. Place the newborn in a prone position. 2. Limit feedings to three a day to decrease diarrhea. 3. Place the infant supine and operate a home apnea-monitoring system. 4. Wean the newborn off the pacifier.
Answer: 1 Explanation: 1. With proper resuscitation, chest movement is observed for proper ventilation. Pressure should be adequate to move the chest wall.
During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations? 1. The rise and fall of the chest 2. Sudden wakefulness 3. Urinary output 4. Adequate thermoregulation
Answer: 4 Explanation: 4. The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a moderate drop in both systolic and diastolic blood pressure, increased pulse pressure, and moderate tachycardia.
During the fourth stage of labor, the client's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse? 1. Turn the client onto her left side. 2. Place the bed in Trendelenburg position. 3. Massage the fundus. 4. Continue to monitor.
Answer: 4, 5 Explanation: 4. The vaginal examination of a laboring client obtains information about the station of the presenting part and the dilation and effacement of the cervix. 5. The vaginal examination of a laboring client obtains information about the fetal presenting part.
During the initial intrapartal assessment of a client in early labor, the nurse performs a vaginal examination. The client's partner asks why this pelvic exam needs to be done. The nurse should explain that the purpose of the vaginal exam is to obtain information about which of the following? Select all that apply. 1. Uterine contraction pattern 2. Fetal position 3. Presence of the mucous plug 4. Cervical dilation and effacement 5. Presenting part
Answer: 4 Explanation: 4. Alpha-fetoprotein (AFP) is a fetal protein that is excreted from the fetal yolk sac during the first 6 weeks of pregnancy. AFP levels can be high or low, with each having different implications for the fetus. If the fetus has a neural tube defect (NTD), the AFP levels will be elevated. NTDs can range from anencephaly to spina bifida. With a past history of a child with spina bifida, this client would be strongly encouraged to have the AFP screening.
Each of the following pregnant women is scheduled for a 14-week antepartal visit. In planning care, the nurse would give priority teaching on amniotic fluid alpha-fetoprotein (AFP) screening to which client? 1. 28-year-old with history of rheumatic heart disease 2. 18-year-old with exposure to HIV 3. 20-year-old with a history of preterm labor 4. 35-year-old with a child with spina bifida
Answer: 1, 2, 5 Explanation: 1. Meconium passage is an indicator for electronic fetal monitoring. 2. Multiple gestation is an indicator for electronic fetal monitoring. 5. Decreased fetal movement is an indicator for electronic fetal monitoring.
Fetal factors that possibly indicate electronic fetal monitoring include which of the following? 1. Meconium passage 2. Multiple gestation 3. Preeclampsia 4. Grand multiparity 5. Decreased fetal movement
4cm-7cm
First Stage-Active Phase: Dilation?
40-70 seconds
First Stage-Active Phase: Duration of Contractions?
3-5 mins
First Stage-Active Phase: Frequency of Contractions?
3hr (P) 2hr (M)
First Stage-Active Phase: How long?
Feels helpless Anxiety & Restlessness as contractions become stronger
First Stage-Active Phase: Mother's reactions?
More regular moderate-strong
First Stage-Active Phase: Quality of Contractions?
0cm-3cm
First Stage-Latent Phase: Dilation?
30-45 secs
First Stage-Latent Phase: Duration of Contractions?
5-30 mins
First Stage-Latent Phase: Frequency of Contractions?
6hr (P) 4hr (M)
First Stage-Latent Phase: How long?
irregular mild-moderate
First Stage-Latent Phase: Quality of Contractions?
8cm-10cm
First Stage-Transition Phase: Dilation?
45-90 seconds
First Stage-Transition Phase: Duration of contractions?
2-3 mins
First Stage-Transition Phase: Frequency of contractions?
20-40 min
First Stage-Transition Phase: How long?
Tired Restless Irritable "Out of control" Urges to push
First Stage-Transition Phase: Mother's reactions?
Strong-very strong
First Stage-Transition Phase: Quality of contractions?
>12.5 hr
First stage of labor: How long?
Onset of labor --> complete dilation
First stage of labor: When to when?
Answer: 1, 2, 3, 5 Explanation: 1. Elevated maternal temperature is a potential side effect of epidural anesthesia. 2. Urinary retention is a potential side effect of epidural anesthesia. 3. Nausea is a potential side effect of epidural anesthesia. 5. Pruritus may occur at any time during the epidural infusion. It usually appears first on the face, neck, or torso and is generally the result of the agent used in the epidural infusion. Benadryl, an antihistamine, can be administered to manage pruritus.
For what common side effects of epidural anesthesia should the nurse watch? Select all that apply. 1. Elevated maternal temperature 2. Urinary retention 3. Nausea 4. Long-term back pain 5. Local itching
Answer: 2 Explanation: 2. Signs of placental separation usually appear around 5 minutes after birth of the infant, but can take up to 30 minutes to manifest. These signs are (1) a globular-shaped uterus, (2) a rise of the fundus in the abdomen, (3) a sudden gush or trickle of blood, and (4) further protrusion of the umbilical cord out of the vagina.
Four minutes after the birth of a baby, there is a sudden gush of blood from the mother's vagina, and about 8 inches of umbilical cord slides out. What action should the nurse take first? 1. Place the client in McRoberts position. 2. Watch for the emergence of the placenta. 3. Prepare for the delivery of an undiagnosed twin. 4. Place the client in a supine position.
Delivery of placenta --> stabilization of maternal VS
Fourth Stage: Beginning to end?
1-4 hr
Fourth Stage: How long?
Answer: 1 Explanation: 1. A shoulder presentation is one type of breech presentation, and is also called a transverse lie.
How would the nurse best analyze the results from a client's sonogram that shows the fetal shoulder as the presenting part? 1. Breech, transverse 2. Breech, longitudinal 3. Breech, frank 4. Vertex, transverse
Answer: 1, 2 Explanation: 1. In order to assess hydration status, volume of urine output must be evaluated. 2. In order to assess hydration status, the infant's weight must be evaluated.
In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include which of the following? Select all that apply. 1. Volume of urine output 2. Weight 3. Blood pH 4. Head circumference 5. Bowel sounds
Answer: 1 Explanation: 1. Eye prophylaxis medication instillation may be delayed up to 1 hour after birth to allow eye contact during parent-newborn bonding.
In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? 1. Eye prophylaxis medication 2. Drying the newborn 3. Vital signs 4. Vitamin K injection
Answer: 1 Explanation: 1. Newborns with fetal alcohol syndrome have feeding problems. Because of their feeding problems, these infants require extra time and patience during feedings.
In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? 1. Allow extra time with feedings. 2. Assign different personnel to the newborn each day. 3. Place the newborn in a well-lit room. 4. Monitor for hyperthermia.
Answer: 4 Explanation: 4. Ascertain fetal heart rate (FHR) before surgery and during preparation because fetal hypoxia can result from aortocaval compression.
In the operating room, a client is being prepped for a cesarean delivery. The doctor is present. What is the last assessment the nurse should make just before the client is draped for surgery? 1. Maternal temperature 2. Maternal urine output 3. Vaginal exam 4. Fetal heart tones
Answer: 2, 4 Explanation: 2. The physician may order amnioinfusion for meconium-stained fluid. 4. Amnioinfusion is sometimes done to prevent the possibility of variable decelerations.
In which clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion? Select all that apply. 1. Placental abruption 2. Meconium-stained fluid 3. Polyhydramnios 4. Variable decelerations 5. Early decelerations
Answer: 3 Explanation: 3. Pitocin should not administered less than 4 hours after the last Cytotec dose.
Induction of labor is planned for a 31-year-old client at 39 weeks due to insulin-dependent diabetes. Which nursing action is most important? 1. Administer 100 mcg of misoprostol (Cytotec) vaginally every 2 hours. 2. Place dinoprostone (Prepidil) vaginal gel and ambulate client for 1 hour. 3. Begin Pitocin (oxytocin) 4 hours after 50 mcg misoprostol (Cytotec). 4. Prepare to induce labor after administering a tap water enema.
Answer: 3 Explanation: 3. Major perineal trauma is more likely to occur if a midline episiotomy is performed. The major disadvantage is that a tear of the midline incision may extend through the anal sphincter and rectum.
Major perineal trauma (extension to or through the anal sphincter) is more likely to occur if what type of episiotomy is performed? 1. Mediolateral 2. Episiorrhaphy 3. Midline 4. Medical
Answer: 1, 4, 5 Explanation: 1. Signs that may be seen in the early infancy period include swollen glands. 4. Signs that may be seen in the early infancy period include rhinorrhea. 5. Signs that may be seen in the early infancy period include interstitial pneumonia.
Many newborns exposed to HIV/AIDS show signs and symptoms of disease within days of birth that include which of the following? Select all that apply. 1. Swollen glands 2. Hard stools 3. Smaller than average spleen and liver 4. Rhinorrhea 5. Interstitial pneumonia
Answer: 2 Explanation: 2. Mild or chronic anemia in an infant may be treated adequately with iron supplements or iron-fortified formulas.
Mild or chronic anemia in an infant may be treated adequately which of the following? 1. Transfusions with O-negative or typed and cross-matched packed red cells 2. Iron supplements or iron-fortified formulas 3. Steroid therapy 4. Antibiotics or antivirals
Answer: 2 Explanation: 2. Analgesia given too late is of no value to the woman and may cause neonatal respiratory depression.
Narcotic analgesia is administered to a laboring client at 10:00 a.m. The infant is delivered at 12:30 p.m. What would the nurse anticipate that the narcotic analgesia could do? 1. Be used in place of preoperative sedation 2. Result in neonatal respiratory depression 3. Prevent the need for anesthesia with an episiotomy 4. Enhance uterine contractions
Answer: 3 Explanation: 3. Foreskin will retract normally over time and may take 3 to 5 years.
New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant? 1. The foreskin will be retractable at 2 months. 2. Retract the foreskin and clean thoroughly. 3. Avoid retracting the foreskin. 4. Use soap and Betadine to cleanse the penis daily.
Answer: 2 Explanation: 2. The biophysical profile is used when there is a risk of placental and/or fetal compromise. The gravida with mild hypotension will need to be monitored more closely throughout the pregnancy, but is not a candidate at present for a biophysical profile.
Of all the clients who have been scheduled to have a biophysical profile, the nurse should check with the physician and clarify the order for which client? 1. A gravida with intrauterine growth restriction 2. A gravida with mild hypotension of pregnancy 3. A gravida who is postterm 4. A gravida who complains of decreased fetal movement for 2 days
Answer: 2 Explanation: 2. Administering intravenous acyclovir (Zovirax) and contact precautions are appropriate measures for an infant at risk for developing herpes simplex 2 infection.
One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate? 1. Meticulous hand washing and antibiotic eye ointment administration. 2. Intravenous acyclovir (Zovirax) and contact precautions. 3. Cultures of blood and CSF and serial chest x-rays every 12 hours. 4. Parental rooming-in and four intramuscular injections of penicillin.
Answer: 4 Explanation: 4. The FASD baby is most comfortable in a quiet, minimally stimulating environment.
Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? 1. "Our baby's heart murmur is from this syndrome." 2. "He might be a fussy baby because of this." 3. "His face looks like it does due to this problem." 4. "Cuddling and rocking will help him stay calm."
Answer: 3 Explanation: 3. Early decelerations are considered benign, and do not require any intervention.
Persistent early decelerations are noted. What would the nurse's first action be? 1. Turn the mother on her left side and give oxygen. 2. Check for prolapsed cord. 3. Do nothing. This is a benign pattern. 4. Prepare for immediate forceps or cesarean delivery.
Answer: 2 Explanation: 2. Breastfeeding should be initiated within the first hour of life unless medically contraindicated.
Placing the baby at mother's breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated? 1. 6 to 12 hours after birth 2. Within 1 hour of birth 3. 24 hours after birth 4. 48 hours after birth
Answer: 1, 2, 4 Explanation: 1. A premonitory sign of labor includes Braxton Hicks contractions. 2. A premonitory sign of labor includes cervical softening and effacement. 4. A premonitory sign of labor includes rupture of membranes.
Premonitory signs of labor include which of the following? Select all that apply. 1. Braxton Hicks contractions 2. Cervical softening and effacement 3. Weight gain 4. Rupture of membranes 5. Sudden loss of energy
Answer: 2, 3, 4 Explanation: 2. Infectious disease screening results help to determine if the infant is also at risk of obtaining any infectious diseases. 3. Gestational diabetes is a risk factor for the newborn. 4. Prolonged rupture of the membranes is a possible risk factor for the infant.
Prior to conducting the initial assessment of a newborn, the nurse reviews the mother's prenatal record and the delivery record to obtain information concerning possible risk factors for the infant and to anticipate the impact of these factors on the infant's ability to successfully transition to the extrauterine environment. Which information is pertinent to this assessment? Select all that apply. 1. Drug or alcohol use by the father 2. Infectious disease screening results 3. Maternal history of gestational diabetes 4. Prolonged rupture of the membranes 5. Maternal use of prenatal vitamins
Answer: 4 Explanation: 4. The woman is positioned on her left or right side, at the edge of the bed with the assistance of the nurse, with her legs slightly flexed, or she is asked to sit on the edge of the bed.
Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring client in which position? 1. On her right side in the center of the bed with her back curved 2. Lying prone with a pillow under her chest 3. On her left side with the bottom leg straight and the top leg slightly flexed 4. Sitting on the edge of the bed
Full dilation --> birth
Second Stage: Beginning to end?
1-2mins
Second Stage: Frequency of Contractions?
30min-2hr (P) 5-30min (M)
Second Stage: How long?
Intense
Second Stage: Quality of Contractions?
Schultz presentation: "Shiny Schultz"
Shiny fetal surface of placenta emerges first
Answer: 4 Explanation: 4. This client is most likely fearful that she will die during labor because her mother died during childbirth. This client requires education and a great deal of support, and is therefore the top priority.
The charge nurse has received the shift change report. Which client requires immediate intervention? 1. Woman at 6 cm undergoing induction of labor, strong contractions every 3 minutes 2. Woman at 4 cm whose fetus is in a longitudinal lie with a cephalic presentation 3. Woman at 10 cm and fetus at +2 station experiencing a strong expulsion urge 4. Woman at 3 cm screaming in fear because her mother died during childbirth
Answer: 1 Explanation: 1. During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is not frequent enough.
The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention? 1. Woman at 7 cm, fetal heart tones auscultated every 90 minutes 2. Woman at 10 cm and pushing, external fetal monitor applied 3. Woman with meconium-stained fluid, internal fetal scalp electrode in use 4. Woman in preterm labor, external monitor in place
Answer: 1, 2, 5 Explanation: 1. CVS has a risk of spontaneous abortion of 0.3% in cases. This rate is higher than second trimester amniocentesis. 2. CVS is performed in some medical centers for first trimester diagnosis after 9 completed weeks. Amniocentesis is performed between 15 and 20 weeks' gestation. 5. Much like amniocentesis, chorionic villus sampling (CVS) is a procedure that is used to detect genetic, metabolic, and DNA abnormalities. CVS permits earlier diagnosis than can be obtained by amniocentesis.
The client and her partner are carriers of sickle-cell disease. They are considering prenatal diagnosis with either amniocentesis or chorionic villus sampling (CVS). Which statements indicate that further teaching is needed on these two diagnostic procedures? Select all that apply. 1. "Chorionic villus sampling carries a lower risk of miscarriage." 2. "Amniocentesis can be done earlier in my pregnancy than CVS." 3. "Neither test will conclusively diagnose sickle-cell disease in our baby." 4. "The diagnosis comes sooner if we have CVS, not amniocentesis." 5. "Amniocentesis is more accurate in diagnosis than the CVS."
Answer: 1 Explanation: 1. Transvaginal ultrasound can most accurately identify shortened cervical length and cervical funneling, which is a cone-shaped indentation in the cervical os indicating cervical insufficiency or risk of preterm labor.
The client at 14 weeks' gestation has undergone a transvaginal ultrasound to assess cervical length. The ultrasound revealed cervical funneling. How should the nurse explain these findings to the client? 1. "Your cervix has become cone-shaped and more open at the end near the baby." 2. "Your cervix is lengthened, and you will deliver your baby prematurely." 3. "Your cervix is short, and has become wider at the end that extends into the vagina." 4. "Your cervix was beginning to open but now is starting to close up again."
Answer: 4, 5 Explanation: 4. Painless bleeding in the second and third trimesters can be a symptom of placenta previa. Transvaginal ultrasound will determine the placental location. 5. Painless bleeding in the second and third trimesters can be a symptom of placenta previa. Transvaginal ultrasound will determine the placental location.
The client at 24 weeks' gestation is experiencing painless vaginal bleeding after intercourse. The physician has ordered a transvaginal ultrasound examination. Which statements by the client indicate an understanding of why this exam has been requested? Select all that apply. 1. "This ultrasound will show the baby's gender." 2. "This ultrasound might cause the miscarriage of my baby." 3. "This ultrasound carries a risk of creating a uterine infection." 4. "This ultrasound can determine the location of my placenta." 5. "This ultrasound might detect whether the placenta is detaching prematurely."
Answer: 3 Explanation: 3. One of the premonitory signs of labor is lightening: The fetus begins to settle into the pelvic inlet (engagement). With fetal descent, the uterus moves downward, and the fundus no longer presses on the diaphragm, which eases breathing.
The client at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make? 1. "You shouldn't work so much at this point in pregnancy." 2. "What you are describing is not commonly experienced in the last weeks." 3. "Your body may be telling you it is going into labor soon." 4. "If the bladder pressure continues, come in to the clinic tomorrow."
Answer: 2 Explanation: 2. Fetal bradycardia occurs when the fetal heart rate falls below 110 beats/minute during a 10-minute period of continuous monitoring. When fetal bradycardia is accompanied by decreased variability, it is considered ominous and could be a sign of fetal compromise.
The client at 39 weeks' gestation is undergoing a cesarean birth due to breech presentation. General anesthesia is being used. Which situation requires immediate intervention? 1. The baby's hands and feet are blue at 1 minute after birth. 2. The fetal heart rate is 70 prior to making the skin incision. 3. Clear fluid is obtained from the baby's oropharynx. 4. The neonate cries prior to delivery of the body.
Answer: 2 Explanation: 2. This is the best response because it most directly addresses what the client has reported.
The client at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best? 1. "Unless you have pain with urination, we don't need to worry about it." 2. "These symptoms usually mean the baby's head has descended further." 3. "Come in for an appointment today and we'll check everything out." 4. "This might indicate that the baby is no longer in a head-down position."
Answer: 3 Explanation: 3. A classic uterine incision is made in the upper uterine segment and is associated with an increased risk of rupture in subsequent pregnancy, labor, and birth. Therefore, subsequent deliveries will be done by Cesarean.
The client demonstrates understanding of the implications for future pregnancies secondary to her classic uterine incision when she states which of the following? 1. "The next time I have a baby, I can try to deliver vaginally." 2. "The risk of rupturing my uterus is too high for me to have any more babies." 3. "Every time I have a baby, I will have to have a cesarean delivery." 4. "I can only have one more baby."
Answer: 3 Explanation: 3. The parents need to be informed that the caput (chignon) on the baby's head will disappear within 2 to 3 days.
The client has been pushing for 2 hours and is exhausted. The physician is performing a vacuum extraction to assist the birth. Which finding is expected and normal? 1. The head is delivered after eight "pop-offs" during contractions. 2. A cephalohematoma is present on the fetal scalp. 3. The location of the vacuum is apparent on the fetal scalp after birth. 4. Positive pressure is applied by the vacuum extraction during contractions.
Answer: 2 Explanation: 2. Vacuum extraction is an assistive delivery. The physician/CNM applies traction in coordination with uterine contractions.
The client has been pushing for two hours, and is exhausted. The fetal head is visible between contractions. The physician informs the client that a vacuum extractor could be used to facilitate the delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance? 1. "A small cup will be put onto the baby's head, and a gentle suction will be applied." 2. "I can stop pushing and just rest if the vacuum extractor is used." 3. "The baby's head might have some swelling from the vacuum cup." 4. "The vacuum will be applied for a total of ten minutes or less."
Answer: 3 Explanation: 3. During the active and transition phases, contractions become more frequent, are longer in duration, and increase in intensity.
The client in early labor asks the nurse what the contractions are like as labor progresses. What would the nurse respond? 1. "In normal labor, as the uterine contractions become stronger, they usually also become less frequent." 2. "In normal labor, as the uterine contractions become stronger, they usually also become less painful." 3. "In normal labor, as the uterine contractions become stronger, they usually also become longer in duration." 4. "In normal labor, as the uterine contractions become stronger, they usually also become shorter in duration."
Answer: 3 Explanation: 3. Fetal heart rate is not a predictor of gender.
The client is being admitted to the birthing unit. As the nurse begins the assessment, the client's partner asks why the fetus's heart rate will be monitored. After the nurse explains, which statement by the partner indicates a need for further teaching? 1. "The fetus's heart rate will vary between 110 and 160." 2. "The heart rate is monitored to see whether the fetus is tolerating labor." 3. "By listening to the heart, we can tell the gender of the fetus." 4. "After listening to the heart rate, you will contact the midwife."
Answer: 4 Explanation: 4. When cord compression is suspected, amnioinfusion (AI) may be considered. AI helps to prevent the possibility of variable decelerations by increasing the volume of amniotic fluid.
The client is having fetal heart rate decelerations. An amnioinfusion has been ordered for the client to alleviate the decelerations. The nurse understands that the type of decelerations that will be alleviated by amnioinfusion is which of the following? 1. Early decelerations 2. Moderate decelerations 3. Late decelerations 4. Variable decelerations
Answer: 2 Explanation: 2. Fetal scalp stimulation is done when there is a question regarding fetal status. An acceleration indicates fetal well-being.
The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse? 1. "I stimulated the top of the fetus's head to wake him up a little." 2. "I stimulated the top of the fetus's head to try to get his heart rate to accelerate." 3. "I stimulated the top of the fetus's head to calm the fetus down before birth." 4. "I stimulated the top of the fetus's head to find out whether he is in distress."
Answer: 3 Explanation: 3. For optimal effect, the ice pack should be applied for 20 to 30 minutes and removed for at least 20 minutes before being reapplied.
The client is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore. Ten minutes after an ice pack is applied, the client asks for another. What is the best response from the nurse? 1. "I'll get you one right away." 2. "You only need to use one ice pack." 3. "You need to leave it off for at least 20 minutes and then reapply." 4. "I'll bring you an extra so that you can change it when you are ready."
Answer: 1, 2, 4 Explanation: 1. Effective measures include allowing the partner to take the baby to the nursery. 2. Effective measures include allowing the partner to be in a place near the operating room, where the newborn's first cry can be heard. 4. Effective measures include involving the partner in postpartum care in the recovery room.
The client is undergoing an emergency cesarean birth for fetal bradycardia. The client's partner has not been allowed into the operating room. What can the nurse do to alleviate the partner's emotional distress? Select all that apply. 1. Allow the partner to wheel the baby's crib to the newborn nursery. 2. Allow the partner to be near the operating room where the newborn's first cry can be heard. 3. Have the partner wait in the client's postpartum room. 4. Encourage the partner to be in the nursery for the initial assessment. 5. Teach the partner how to take the client's blood pressure.
Answer: 2 Explanation: 2. The client should be monitored using electronic fetal monitoring for at least 30 minutes and up to 2 hours after placement to assess the contraction pattern and the fetal status.
The client presents for cervical ripening in anticipation of labor induction tomorrow. What should the nurse include in her plan of care for this client? 1. Apply an internal fetal monitor. 2. Monitor the client using electronic fetal monitoring. 3. Withhold oral intake and start intravenous fluids. 4. Place the client in a upright, sitting position.
Answer: 3 Explanation: 3. Maternal temperature is taken every 4 hours unless it is above 37.5°C. If elevated, it is taken every hour.
The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Barring any abnormalities, how often would the nurse expect to take the client's temperature? 1. Every hour 2. Every 2 hours 3. Every 4 hours 4. Every shift
Answer: 1, 2, 5 Explanation: 1. Fetal heart rate (FHR) of 110-160 with average variability is a normal indication. 2. Maternal vital sign of blood pressure below 140/90 is a normal indication. 5. Fluid clear and without odor if membranes ruptured is a normal indication.
The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Indicators of normal labor include which of the following? Select all that apply. 1. Fetal heart rate of 130 with average variability 2. Blood pressure of 130/80 3. Maternal pulse of 160 4. Protein of +1 in urine 5. Odorless, clear fluid on underwear
3. A mediolateral episiotomy is angled from the vaginal opening toward the buttock. It begins in the midline of the posterior fourchette and extends at a 45-degree angle downward to the right or left.
The client requires vacuum extraction assistance. To provide easier access to the fetal head, the physician cuts a mediolateral episiotomy. After delivery, the client asks the nurse to describe the episiotomy. What does the nurse respond? 1. "The episiotomy goes straight back toward your rectum." 2. "The episiotomy is from your vagina toward the urethra." 3. "The episiotomy is cut diagonally away from your vagina." 4. "The episiotomy extends from your vagina into your rectum."
Answer: 1 Explanation: 1. Version, or turning the fetus, is a procedure used to change the fetal presentation by abdominal or intrauterine manipulation.
The client tells the nurse that she has come to the hospital so that her baby's position can be changed. The nurse would begin to organize the supplies needed to perform which procedure? 1. A version 2. An amniotomy 3. Leopold maneuvers 4. A ballottement
Answer: 3 Explanation: 3. Even when food and fluids have been withheld, the gastric juice produced during fasting is highly acidic and can produce chemical pneumonitis if aspirated. This pneumonitis is known as Mendelson syndrome. The signs and symptoms are chest pain, respiratory distress, cyanosis, fever, and tachycardia. Women undergoing emergency cesarean births appear to be at considerable risk for adverse events.
The client with a normal pregnancy had an emergency cesarean birth under general anesthesia 2 hours ago. The client now has a respiratory rate of 30, pale blue nail beds, a pulse rate of 110, and a temperature of 102.6°F, and is complaining of chest pain. The nurse understands that the client most likely is experiencing which of the following? 1. Pulmonary embolus 2. Pneumococcal pneumonia 3. Pneumonitis 4. Gastroesophageal reflux disease
Answer: 3 Explanation: 3. Ultrasound is used to detect neural tube defects. An abnormal serum quadruple screen is not the result of a lab error, and can indicate either an open neural tube defect or trisomy 18 or 21.
The client with an abnormal quadruple screen is scheduled for an ultrasound. Which statement indicates that the client understands the need for this additional antepartal fetal surveillance? 1. "After the ultrasound, my partner and I will decide how to decorate the nursery." 2. "During the ultrasound we will see which of us the baby looks like most." 3. "The ultrasound will show whether there are abnormalities with the baby's spine." 4. "The blood test wasn't run correctly, and now we need to have the sonogram."
Answer: 2 Explanation: 2. This explanation is accurate and easy for the client to understand. Newborns of Rh-negative and O blood type mothers are carefully assessed for blood type status, appearance of jaundice, and levels of serum bilirubin.
The client with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse? 1. "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." 2. "Your body has made antibodies against the baby's blood that are destroying her red blood cells." 3. "The red blood cells of your baby are breaking down because you both have type O blood." 4. "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."
Answer: 2 Explanation: 2. Powdered formula is the least expensive type of formula. Parents will need to be briefed on safety precautions during formula preparation and they should be instructed to follow the directions on the formula package label precisely as written.
The community nurse is working with poor women who are formula-feeding their infants. Which statement indicates that the nurse's education session was effective? 1. "I should use only soy-based formula for the first year." 2. "I follow the instructions for mixing the powdered formula exactly." 3. "It is okay to add more water to the formula to make it last longer." 4. "The mixed formula can be left on the counter for a day."
Answer: 1 Explanation: 1. The fetus is exhibiting variable decelerations, which are caused by cord compression. Sometimes late or variable decelerations are due to the supine position of the laboring woman. In this case, the decrease in uterine blood flow to the fetus may be alleviated by raising the woman's upper trunk or turning her to the side to displace pressure of the gravid uterus on the inferior vena cava.
The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? 1. Assist the client to change position. 2. Apply oxygen to the client at 2 liters per nasal cannula. 3. Notify the operating room of the need for a cesarean birth. 4. Determine the color of the leaking amniotic fluid.
Answer: 3 Explanation: 3. Late decelerations are considered a nonreassuring fetal heart rate (FHR) pattern, and therefore require immediate intervention.
The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention? 1. Early decelerations with each contraction 2. Variable decelerations that recover to the baseline 3. Late decelerations with minimal variability 4. Accelerations
Answer: 3 Explanation: 3. It is important for the woman to relax each part of her body. Be alert for signs of muscle tension and tightening. Dissociative relaxation, controlled muscle relaxation, and specified breathing patterns are used to promote birth as a normal process.
The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor? 1. Increased pulse 2. Elevated blood pressure 3. Muscle tension 4. Increased respirations
Answer: 2 Explanation: 2. Average cervical change in the active phase of the first stage of labor is 1.2 cm/hour; thus, this client's lack of cervical change is unexpected, and should be reported to the supervisor.
The labor and delivery nurse is reviewing charts. The nurse should inform the supervisor about which client? 1. Client at 5 cm requesting labor epidural analgesia 2. Client whose cervix remains at 6 cm for 4 hours 3. Client who has developed nausea and vomiting 4. Client requesting her partner to stay with her
Answer: 1, 2, 3 Explanation: 1. If the cervix is not completely dilated, maternal exhaustion can occur. 2. If the cervix is not completely dilated, cervical edema can occur. 3. If the cervix is not completely dilated, tearing and bruising of the cervix can occur.
The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following? Select all that apply. 1. Maternal exhaustion 2. Cervical edema 3. Tearing and bruising of the cervix 4. Enhanced perineal thinning 5. Having to perform an episiotomy
Answer: 2 Explanation: 2. It is important to establish rapport and to create a welcoming environment
The laboring client and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first? 1. The sterile vaginal exam 2. Welcoming the couple 3. Auscultation of the fetal heart rate 4. Checking for ruptured membranes
Answer: 2 Explanation: 2. Maternal hypotension results in uteroplacental insufficiency in the fetus, which is manifested as late decelerations on the fetal monitoring strip. The risk of hypotension can be minimized by hydrating the vascular system with 500 to 1000 mL of IV solution before the procedure and changing the woman's position and/or increasing the IV rate afterward.
The laboring client brought a written birth plan indicating that she wanted to avoid pain medications and an epidural. She is now at 6 cm and states, "I can't stand this anymore! I need something for pain! How will an epidural affect my baby?" What is the nurse's best response? 1. "The narcotic in the epidural will make both you and the baby sleepy." 2. "It is unlikely that an epidural will decrease your baby's heart rate." 3. "Epidurals tend to cause low blood pressure in babies after birth." 4. "I can't get you an epidural, because of your birth plan."
Answer: 2 Explanation: 2. The client is exhibiting signs of acute pain, which is both common and expected in the transitional phase of labor.
The laboring client is at 7 cm, with the vertex at a +1 station. Her birth plan indicates that she and her partner took Lamaze prenatal classes, and they have planned on a natural, unmedicated birth. Her contractions are every 3 minutes and last 60 seconds. She has used relaxation and breathing techniques very successfully in her labor until the last 15 minutes. Now, during contractions, she is writhing on the bed and screaming. Her labor partner is rubbing the client's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this client? 1. Fear/Anxiety related to discomfort of labor and unknown labor outcome 2. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent 3. Coping: Family, Compromised, related to labor process 4. Knowledge, Deficient, related to lack of information about normal labor process and comfort measures
Answer: 2 Explanation: 2. Clients who participate in childbirth classes that stress the normalcy of birth may feel a sense of loss or failure if an intervention is used during their labor or birth.
The laboring client participated in childbirth preparation classes that strongly discouraged the use of medications and intervention during labor. The client has been pushing for two hours, and is exhausted. The physician requests that a vacuum extractor be used to facilitate the birth. The client first states that she wants the birth to be normal, then allows the vacuum extraction. Following this, what should the nurse assess the client for after the birth? 1. Elation, euphoria, and talkativeness 2. A sense of failure and loss 3. Questions about whether or not to circumcise 4. Uncertainty surrounding the baby's name
Answer: 3 Explanation: 3. Electronic fetal monitoring (EFM) provides a continuous tracing of the fetal heart rate (FHR), allowing characteristics of the FHR to be observed and evaluated.
The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? 1. "The monitor is necessary so we can see how your labor is progressing." 2. "The monitor will prevent complications from the meconium in your fluid." 3. "The monitor helps us to see how the baby is tolerating labor." 4. "The monitor can be removed, and oxygen given instead."
Answer: 1 Explanation: 1. The described fetal heart rate has a normal baseline; the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary.
The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best? 1. Document the fetal heart rate. 2. Apply oxygen via mask at 10 liters. 3. Prepare for imminent delivery. 4. Assist the client into Fowler's position.
Answer: 4 Explanation: 4. A -2 station means that the fetus is 2 cm above the ischial spines. The ischial spines as a landmark have been designated as zero station. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. With the fetus's head that high in the pelvis, it is difficult to predict when birth will occur.
The midwife performs a vaginal exam and determines that the fetal head is at a -2 station. What does this indicate to the nurse about the birth? 1. The birth is imminent. 2. The birth is likely to occur in 1-2 hours. 3. The birth will occur later in the shift. 4. The birth is difficult to predict.
Answer: 1 Explanation: 1. Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers.
The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurse's best response? 1. "Most newborns are nose breathers." 2. "The tube will elicit the sucking reflex." 3. "A smaller catheter is preferred for feedings." 4. "Most newborns are mouth breathers."
Answer: 2 Explanation: 2. Low forceps are applied when the leading edge of the fetal head is at +2 station.
The need for forceps has been determined. The client's cervix is dilated to 10 cm, and the fetus is at +2 station. What category of forceps application would the nurse anticipate? 1. Input 2. Low 3. Mid 4. Outlet
Answer: 4 Explanation: 4. Preterm babies have little subcutaneous fat, and do not maintain their body temperature well. Formula should be warmed prior to feedings to help the baby maintain its temperature.
The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? 1. The new nurse holds the infant after giving a gavage feeding. 2. The new nurse provides skin-to-skin care. 3. The new nurse provides care when the baby is awake. 4. The new nurse gives the feeding with room-temperature formula.
Answer: 2 Explanation: 2. The absence of cervicovaginal fFN between 20 and 34 weeks' gestation has been shown to be a strong predictor of a woman not experiencing preterm birth due to spontaneous preterm labor or premature rupture of membranes. Positive findings indicate a 99% probability of birth within the next 2 weeks.
The nurse anticipates that the physician will most likely order a cervicovaginal fetal fibronectin test for which client? 1. The client at 34 weeks' gestation with gestational diabetes 2. The client at 32 weeks' gestation with regular uterine contractions 3. The client at 37 weeks' multi-fetal gestation 4. The client at 20 weeks' gestation with ruptured amniotic membranes
Answer: 2 Explanation: 2. The normal respiratory rate is 30-60 breaths/min; 68 breaths/min could represent a less-than-ideal transition.
The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be which of the following? 1. Temperature 97.9°F 2. Respirations 68 breaths/minute 3. Vital signs stable for only 2 hours 4. Heart rate 156 beats/min
Answer: 3 Explanation: 3. Poor suck, gag, and swallow reflexes are characteristic of a preterm newborn
The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. Which of the following assessment findings is not congruent with prematurity? 1. Cry is weak and feeble 2. Clitoris and labia minora are prominent 3. Strong sucking reflex 4. Lanugo is plentiful
Answer: 4 Explanation: 4. Nasal flaring and facial grimacing are signs of respiratory distress.
The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about? 1. Neonatal jaundice 2. Neonatal hypothermia 3. Neonatal hyperthermia 4. Respiratory distress
Answer: 1 Explanation: 1. A fetal heart rate of 112 beats/min. falls within the normal range of 110-160 beats/min., so there is no need to inform the doctor.
The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate? 1. Inform the maternal client that the rate is normal. 2. Reassess the FHR in 5 minutes because the rate is low. 3. Report the FHR to the doctor immediately. 4. Turn the maternal client on her side and administer oxygen.
Answer: 1, 2, 3, 4 Explanation: 1. The initial laboratory workup for anemia should include hemoglobin measurements. 2. The initial laboratory workup for anemia should include hematocrit measurements. 3. The initial laboratory workup for anemia should include a reticulocyte count. 4. The direct Coombs' test reveals the presence of antibody-coated (sensitized) Rh-positive red blood cells in the newborn and should be included in the initial laboratory workup for anemia.
The nurse caring for a newborn with anemia would expect which initial laboratory data to be included in the initial assessment? Select all that apply. 1. Hemoglobin 2. Hematocrit 3. Reticulocyte count 4. Direct Coombs' test 5. Cord serum OgM
Answer: 4 Explanation: 4. Breastfeeding is an appropriate means of feeding for the postterm newborn.
The nurse caring for a post-term newborn would not perform what intervention? 1. Providing warmth 2. Frequently monitoring blood glucose 3. Observing respiratory status 4. Restricting breastfeeding
Answer: 2, 4, 5 Explanation: 2. A fetus with an arm presenting is likely in a horizontal lie. 4. A fetus with a left scapula presenting is in a horizontal lie. 5. A fetus with a right scapula presenting is in a horizontal lie.
The nurse determines that a client is carrying her fetus in the vertical (longitudinal) lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? Select all that apply. 1. Sacrum 2. Left arm 3. Mentum 4. Left scapula 5. Right scapula
Answer: 1, 3, 4 Explanation: 1. Early breastfeeding stimulates the newborn's peristalsis. 3. Early breastfeeding enhances maternal-infant bonding. 4. Early breastfeeding promotes the passage of meconium.
The nurse encourages a new mother to feed the newborn as soon as the newborn shows interest. The nurse bases this recommendation on which benefits of early feedings? Select all that apply. 1. Early feedings stimulate peristalsis. 2. Colostrum is thinner than mature milk. 3. Early feedings enhance maternal-infant bonding. 4. Early feedings promote the passage of meconium. 5. Colostrum contains a high number of calories.
Answer: 1 Explanation: 1. Newborns should gain at least 10 g/kg/day and be back to birth weight no later than day 14 of life.
The nurse has completed a community education session on growth patterns of infants. Which statement by a participant indicates that additional teaching is needed? 1. "Newborns should regain their birth weight by 1 week of age." 2. "Breastfed and formula-fed babies have different growth rates." 3. "Formula-fed infants regain their birth weight earlier than breastfed infant." 4. "Healthcare providers consider breastfeeding to be the 'gold standard' for neonatal nutrition."
Answer: 1, 2, 3, 5 Explanation: 1. Risk factors such as the use of drugs or alcohol during the pregnancy can influence the labor and birth. 2. It is imperative to ask the woman about domestic violence and to assess any degree of psychologic or physical harm, either potential or real. 3. A social assessment includes asking about the woman's current living situation. This dialog provides an opportunity for the nurse to continue to build support, to provide information when requested, and to be direct yet supportive. 5. A social assessment includes asking about resources available to the family.
The nurse has completed the physical assessment of a client in early labor, and proceeds with the social assessment. A social history of the client would include which of the following? Select all that apply. 1. Use of drugs and alcohol 2. Family violence or sexual assault 3. Current living situation 4. Type of insurance 5. Availability of resources
Answer: 3 Explanation: 3. Swaddling or bundling the baby increases a sense of security and is a quieting activity.
The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what? 1. Hold the newborn in an upright position. 2. Massage the hands and feet. 3. Swaddle the newborn in a blanket. 4. Make eye contact while talking to the newborn.
Answer: 2 Explanation: 2. The nurse rechecks the temperature after the bath and, if it is stable, dresses the newborn in a shirt, diaper, and cap; wraps the baby; and places the baby in an open crib at room temperature. If the baby's axillary temperature is below 36.5°C (97.7°F), the nurse returns the baby to the radiant warmer. The rewarming process should be gradual to prevent the possibility of hyperthermia.
The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data? 1. Heart rate 120 2. Temperature 96.8°F 3. Respiratory rate 50 4. Temperature 99.6°F
Answer: 4 Explanation: 4. Strong intensity exists when the uterine wall cannot be indented.
The nurse has just palpated a laboring woman's contractions. The uterus cannot be indented during a contraction. What would the intensity of these contractions best be characterized as? 1. Weak 2. Mild 3. Moderate 4. Strong
Answer: 3 Explanation: 3. The consistency of strong contractions is similar to that of the forehead.
The nurse has just palpated contractions and compares the consistency to that of the forehead to estimate the firmness of the fundus. What would the intensity of these contractions be identified as? 1. Mild 2. Moderate 3. Strong 4. Weak
Answer: 4 Explanation: 4. Local anesthetics are not used for labor pain relief. They are used prior to episiotomy and for laceration repair.
The nurse has presented a session on pain relief options to a prenatal class. Which statement indicates that additional teaching is needed? 1. "An epidural can be continuous or can be given in one dose." 2. "A spinal is usually used for a cesarean birth." 3. "Pudendal blocks are effective when a vacuum is needed." 4. "Local anesthetics provide good labor pain relief."
Answer: 3 Explanation: 3. Nasal flaring is an indication of respiratory distress. The nurse must be immediately available to provide appropriate interventions for a newborn in distress.
The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? 1. 37-week male, respiratory rate 45 2. 8 pound 1 ounce female, pulse 150 3. Term male, nasal flaring 4. 4-hour-old female who has not voided
Answer: 1, 3, 4 Explanation: 1. The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing vital signs (body temperature, heart rate, respiratory rate). 3. The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing airway clearance. 4. The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing ability to feed.
The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing which of the following? Select all that apply. 1. Respiratory rate 2. Skin texture 3. Airway clearance 4. Ability to feed 5. Head weight
Answer: 1, 2, 5 Explanation: 1. Successful eye prophylaxis requires that the medication be instilled in the lower conjunctival sac of each eye. 2. After administration, the nurse massages the eyelid gently to distribute the ointment. 5. Eye prophylaxis medication can cause chemical conjunctivitis, which gives the newborn some discomfort and can interfere with the baby's ability to focus on the parents' faces.
The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Select all that apply. 1. The medication should be instilled in the lower conjunctival sac of each eye. 2. The eyelids should be massaged gently to distribute the ointment. 3. The medication must be given immediately after delivery. 4. The medication does not cause any discomfort to the infant. 5. The medication can interfere with the baby's ability to focus.
Answer: 2 Explanation: 2. The expectant mother's partner or support person is an important member of the birthing team, and assessments of the couple's coping, interactions, and teamwork are integral to the nurse's knowledge base. The nurse's physical presence with the laboring woman provides the best opportunity for ongoing assessment.
The nurse is admitting a client to the birthing unit. What question should the nurse ask to gain a better understanding of the client's psychosocial status? 1. "How did you decide to have your baby at this hospital?" 2. "Who will be your labor support person?" 3. "Have you chosen names for your baby yet?" 4. "What feeding method will you use for your baby?"
Answer: 3 Explanation: 3. Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both mother and fetus.
The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician? 1. Blood pressure 120/88 2. Father a carrier of sickle-cell trait 3. Dark red vaginal bleeding 4. History of domestic abuse
Answer: 4 Explanation: 4. Central cyanosis is defined as a visible, blue discoloration of the skin caused by decreased oxygen saturation levels and is a common manifestation of a cardiac defect.
The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect? 1. Apical heart rate of 140 beats per minute 2. Respiratory rate of 40 3. Temperature of 36.5°C 4. Visible, blue discoloration of the skin
Answer: 3 Explanation: 3. Late decelerations are caused by uteroplacental insufficiency. The late deceleration pattern is considered a nonreassuring sign.
The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following? 1. Moderate variability 2. Early decelerations 3. Late decelerations 4. Accelerations
Answer: 4 Explanation: 4. One-to-one teaching while the nurse is in the mother's room is shown to be the most effective educational model. Individual instruction is helpful to answer specific questions.
The nurse is analyzing various teaching strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? 1. Select videos on various topics of newborn care. 2. Organize a class that includes first-time mothers only. 3. Have mothers return in 1 week, when they feel more rested. 4. Schedule time for one-to-one teaching in the mother's room.
Answer: 2 Explanation: 2. The infant is term and was born by cesarean, and is most likely experiencing transient tachypnea of the newborn.
The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition? 1. Meconium aspiration syndrome 2. Transient tachypnea of the newborn 3. Respiratory distress syndrome 4. Prematurity of the neonate
Answer: 3 Explanation: 3. Jitteriness and irritability can be an indicator of drug withdrawal.
The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse? 1. Occasional watery stools 2. Spitting up after feeding 3. Jitteriness and irritability 4. Nasal stuffiness
Answer: 2, 3 Explanation: 2. Physiologic or neonatal jaundice is a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life. 3. Jaundice is a yellowish coloration of the skin and sclera of the eyes that develops from the deposit of yellow pigment bilirubin in lipid/fat-containing tissues.
The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse expect? Select all that apply. 1. Jaundice present within the first 24 hours of life 2. Appearance of jaundice symptoms after 24 hours of life 3. Yellowish coloration of the sclera of the eyes 4. Cephalohematoma or excessive bruising 5. Cyanosis
Answer: 3, 5 Explanation: 3. Tachycardia would be a sign of shock. 5. Capillary filling time greater than 3 seconds would be a sign of shock.
The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock? Select all that apply. 1. Increased pulse 2. High blood pressure 3. Tachycardia 4. Bradycardia 5. Capillary filling time greater than 3 seconds
Answer: 2 Explanation: 2. Crying results in increased ingestion of air even before the infant has started feeding. Infants who are very hungry also gulp more air. For these situations, instruct the parents to burp their infant frequently.
The nurse is assisting a mother to bottle-feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should do which of the following? 1. Offer a pacifier 2. Burp the newborn 3. Unwrap the newborn 4. Stroke the newborn's spine and feet
Answer: 3 Explanation: 3. A fetus that is not experiencing stress responds to scalp stimulation with an acceleration of the FHR.
The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip? 1. Late decelerations 2. Early decelerations 3. Accelerations 4. Fetal dysrhythmia
Answer: 3 Explanation: 3. The most common fetal position is occiput anterior. When this position occurs, labor and birth are likely to proceed normally.
The nurse is aware that labor and birth will most likely proceed normally when the fetus is in what position? 1. Right-acromion-dorsal-anterior 2. Right-sacrum-transverse 3. Occiput anterior 4. Posterior position
Answer: 1 Explanation: 1. Tremors are a sign of hypocalcemia. Diabetic mothers tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant.
The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority? 1. Obtain a blood calcium level. 2. Take the newborn's temperature. 3. Obtain a bilirubin level. 4. Place a pulse oximeter on the newborn.
Answer: 1, 2, 4 Explanation: 1. As the fetal head continues its descent, the perineum begins to bulge, flatten, and move anteriorly. 2. Bloody show increases as a woman enters the second stage of labor. 4. As the fetal head descends, the woman has the urge to push because of pressure of the fetal head on the sacral and obturator nerves.
The nurse is caring for a client in labor. Which signs and symptoms would indicate the client is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum 2. Increased bloody show 3. Spontaneous rupture of the membranes 4. Uncontrollable urge to push 5. Inability to breathe through contractions
Answer: 1, 5 Explanation: 1. The tracing is normal, so the nurse can continue support of the labor. 5. The nurse can reassure the client at this time, as the tracing is normal.
The nurse is caring for a client in the transition phase of labor and notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute. What actions should the nurse take in this situation? Select all that apply. 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous. 5. Reassure the client and her partner that she is doing fine.
Answer: 1, 2, 3, 4 Explanation: 1. Maternal dehydration can cause fetal tachycardia. 2. Maternal hyperthyroidism can cause fetal tachycardia. 3. Fetal tachycardia can indicate fetal hypoxia. 4. Prematurity can cause fetal tachycardia.
The nurse is caring for a client who is having fetal tachycardia. The nurse knows that possible causes include which of the following? Select all that apply. 1. Maternal dehydration 2. Maternal hyperthyroidism 3. Fetal hypoxia 4. Prematurity 5. Anesthesia or regional analgesia
Answer: 1, 2, 4, 5 Explanation: 1. Fetal anemia can cause a sinusoidal heart rate. 2. Chronic fetal bleeding can cause a sinusoidal heart rate. 4. Twin-to-twin transfusion will cause a sinusoidal heart rate. 5. Umbilical cord occlusion can cause a sinusoidal fetal heart rate.
The nurse is caring for a client who is showing a sinusoidal fetal heart rate pattern on the monitor. The nurse knows that possible causes for this pattern include which of the following? Select all that apply. 1. Fetal anemia 2. Chronic fetal bleeding 3. Maternal hypotension 4. Twin-to-twin transfusion 5. Umbilical cord occlusion
Answer: 2 Explanation: 2. Temperature assessment is indicated to detect hypothermia or hyperthermia. Normal temperature ranges are 97.7°F-98.6°F. Vital signs should be monitored every 4 hours with axillary temperatures.
The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? 1. Eyes are covered, no clothing on, diaper in place 2. Axillary temperature 99.7°F 3. Infant removed from the isolette for breastfeeding 4. Loose bowel movement
Answer: 1 Explanation: 1. General anesthesia will be recommended. Women with thrombocytopenia should avoid regional blocks.
The nurse is caring for a laboring client with thrombocytopenia. During labor, it is determined that the client requires a cesarean delivery. The nurse is preparing the client for surgery, and should instruct the client that the recommended method of anesthesia is which of the following? 1. General anesthesia 2. Epidural anesthesia 3. Spinal anesthesia 4. Regional anesthesia
Answer: 4 Explanation: 4. Because the client is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the client and reassuring her that she will not be alone are the highest priorities at this time.
The nurse is caring for a laboring client. A cervical exam indicates 8 cm dilation. The client is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important? 1. Leave the client alone so she can rest. 2. Ask the family to take a coffee-and-snack break. 3. Encourage the client to have an epidural for pain. 4. Reassure the client that she will not be left alone.
Answer: 4 Explanation: 4. Among some traditional cultures around the world, it is believed that colostrum is "unclean" or even harmful to a newborn. Because of this ancient belief, mothers living the Middle East and parts of Asia even today discard their colostrum or wait 2 to 4 days to begin breastfeeding, when their "true milk" arrives. This mother would begin breastfeeding the third or fourth day after the birth.
The nurse is caring for a new breastfeeding mother who is from Pakistan. The nurse plans her care so that the newborn is offered the breast on which of the following? 1. Day of birth 2. First day after birth 3. Second day after birth 4. Third to fourth day after birth
Answer: 4 Explanation: 4. Myelomeningocele is a saclike cyst containing meninges, spinal cord, and nerve roots in thoracic and/or lumbar area. Meticulous cleaning of the buttocks and genitals helps prevent infection. The infant is positioned on abdomen or on side and restrain (to prevent pressure and trauma to sac). Hydrocephalus often is present.
The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with which of the following? 1. Omphalocele 2. Gastroschisis 3. Diaphragmatic hernia 4. Myelomeningocele
Answer: 2 Explanation: 2. It is important to observe for the first voiding after a circumcision to evaluate for urinary obstruction related to penile injury and/or edema.
The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? 1. Keep the infant NPO for 4 hours following the procedure. 2. Observe for urine output. 3. Wrap dry gauze tightly around the penis. 4. Clean with cool water with each diaper change.
Answer: 1, 2, 4, 5 Explanation: 1. The infant has congenital hydrocephalus. The nurse should measure and plot occipital-frontal baseline measurements, then measure head circumference once a day. 2. The infant has congenital hydrocephalus. Fontanelles should be checked for bulging and sutures for widening. 4. Infants with hydrocephalus are prone to infection. 5. The infant has congenital hydrocephalus. The enlarged head should be supported with a gel pillow.
The nurse is caring for a newborn with full fontanelles and "setting sun" eyes. Which nursing interventions should be included in the care plan? Select all that apply. 1. Measure head circumference daily. 2. Assess for bulging fontanelles. 3. Avoid position changes. 4. Watch for signs of infection. 5. Use a gel pillow under the head.
Answer: 1, 2, 4, 5 Explanation: 1. With the fiber-optic blanket, the light stays on at all times. 2. The eyes do not have to be covered with a fiber optic blanket. 4. With the fiber-optic blanket, greater surface area is exposed and there are no thermoregulation issues. 5. Fluid and weight loss are not complications of fiber-optic blankets.
The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following? Select all that apply. 1. Lights can stay on all the time. 2. The eyes do not need to be covered. 3. The lights will need to be removed for feedings. 4. Newborns do not get overheated. 5. Weight loss is not a complication of this system.
Answer: 4 Explanation: 4. Previously frozen thawed breast milk is good in the refrigerator for 24 hours only.
The nurse is caring for a premature infant in the NICU, and is going to attempt a bottle feeding with thawed breast milk. How long can thawed breast milk be stored in the refrigerator before the nurse must discard it? 1. 4 hours 2. 8 hours 3. 12 hours 4. 24 hours
Answer: 1, 3, 4, 5 Explanation: 1. Low socioeconomic status is associated with at-risk newborns. 3. Exposure to environmental dangers, such as toxic chemicals is associated with at-risk newborns. 4. Maternal factors such as multiparity are associated with at-risk newborns. 5. Preexisting maternal conditions, such as heart disease, diabetes, hypertension, hyperthyroidism, and renal disease are associated with at-risk newborns.
The nurse is caring for a prenatal client. Reviewing the client's pregnancy history, the nurse identifies risk factors for an at-risk newborn, including which of the following? Select all that apply. 1. The mother's low socioeconomic status 2. Maternal age of 26 3. Mother's exposure to toxic chemicals 4. More than three previous deliveries 5. Maternal hypertension
Answer: 3 Explanation: 3. The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is small for gestational age. Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR.
The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart? 1. Preterm appropriate for gestational age, symmetrical IUGR 2. Term small for gestational age, symmetrical IUGR 3. Preterm small for gestational age, asymmetrical IUGR 4. Preterm appropriate for gestational age, asymmetrical IUGR
Answer: 1, 3, 4, 5 Explanation: 1. Tremors are a clinical sign of hypocalcemia. 3. Hyperbilirubinemia is caused by slightly decreased extracellular fluid volume, which increases the hematocrit level. 4. Respiratory distress syndrome (RDS) is a complication that occurs more frequently in newborns of diabetic mothers whose diabetes is not well controlled. 5. Because most IDMs are macrosomic, trauma may occur during labor and vaginal birth resulting in shoulder dystocia, brachial plexus injuries, subdural hemorrhage, cephalohematoma, and asphyxia.
The nurse is caring for an infant of a diabetic mother. Which potential complications would the nurse consider in planning care for this newborn? Select all that apply. 1. Tremors 2. Hyperglycemia 3. Hyperbilirubinemia 4. Respiratory distress syndrome 5. Birth trauma
Answer: 3 Explanation: 3. IV fluids should be warmed prior to administration and the newborn can be wrapped in a chemically activated warming mattress immediately following birth to decrease the postnatal fall in temperature that normally occurs.
The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention? 1. Increased skin temperature and respirations 2. Blood glucose level of 45 3. Room-temperature IV running 4. Positioned under radiant warmer
Answer: 1 Explanation: 1. A common cause of neonatal distress is early-onset group B streptococcal (GBS) disease. Infected mothers transmit GBS infection to their infants during labor and birth. All infants of mothers identified as at risk should be assessed and observed for signs and symptoms of sepsis.
The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? 1. The infant's mother has group B streptococcal (GBS) disease. 2. The infant's mother had an IV of lactated Ringer's solution. 3. The infant's mother had a labor that lasted 12 hours. 4. The infant's mother had a cesarean birth with her last child.
Answer: 3, 4, 5 Explanation: 3. A transverse lie occurs when the cephalocaudal axis of the fetal spine is at a right angle to the woman's spine and is associated with a shoulder presentation and can lead to complications in the later stages of labor. 4. Station refers to the relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. A -2 station is high in the pelvis. Contractions should be strong to cause fetal descent. Mild contractions will not move the baby down or open the cervix. This client is experiencing a problem between the maternal pelvis and the presenting part. 5. When the fetal shoulder is the presenting part, the fetus is in a transverse lie and the acromion process of the scapula is the landmark. This type of presentation occurs less than 1% of the time. This client is experiencing a problem between the maternal pelvis and the presenting part.
The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor? Select all that apply. 1. Woman at 7 cm, fetus in general flexion 2. Woman at 3 cm, fetus in longitudinal lie 3. Woman at 4 cm, fetus with transverse lie 4. Woman at 6 cm, fetus at -2 station, mild contractions 5. Woman at 5 cm, fetal presenting part is right shoulder
Answer: 1 Explanation: 1. This client is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic.
The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? 1. 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory 2. 23-year-old of low socioeconomic status, unmarried 3. 16-year-old who began prenatal care at 30 weeks 4. 28-year-old with a history of gestational diabetes
Answer: 1 Explanation: 1. IDMs whose serum glucose falls below 40 mg/dL should have early feedings with formula or breast milk (colostrum).
The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn? 1. Offer early feedings with formula or breast milk. 2. Provide glucose water exclusively. 3. Evaluate blood glucose levels at 12 hours after birth. 4. Assess for hypothermia.
Answer: 1 Explanation: 1. Newborns of diabetic mothers may benefit from early feeding as they are extremely valuable in maintaining normal metabolism and lowering the possibility of such complications as hypoglycemia and hyperbilirubinemia.
The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurse's plan of care for this newborn? 1. Offer early feedings. 2. Administer an intravenous infusion of glucose. 3. Assess for hypercalcemia. 4. Assess for hyperbilirubinemia immediately after birth.
Answer: 1, 3, 5 Explanation: 1. Newborns born to drug-addicted mothers exhibit hyperirritability. 3. Newborns born to drug-addicted mothers exhibit exaggerated reflexes. 5. Newborns born to drug-addicted mothers exhibit transient tachypnea.
The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? Select all that apply. 1. Hyperirritability 2. Decreased muscle tone 3. Exaggerated reflexes 4. Low pitched cry 5. Transient tachypnea
Answer: 4 Explanation: 4. This statement is incorrect. The major disadvantage is that a tear of the midline incision may extend through the anal sphincter and rectum.
The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement by the client indicates that further information is required? 1. "Because I have a midline episiotomy, I should keep my perineum clean." 2. "I can use an ice pack to relieve some the pain from the episiotomy." 3. "I can take ibuprofen (Motrin) when my perineum starts to hurt." 4. "The tear I have through my rectum is unrelated to my episiotomy."
Answer: 1 Explanation: 1. Putting a baby to bed with a propped bottle is a choking hazard, and should never be done.
The nurse is completing the discharge teaching of a young first-time mother. Which statement by the mother requires immediate intervention? 1. "I will put my baby to bed with his bottle so he doesn't get hungry during the night." 2. "My baby will probably have a bowel movement each breastfeeding, and will wet often." 3. "Nursing every 2 to 3 hours is normal, for a total of 8 to 12 feedings every day." 4. "I will drink fenugreek tea from my grandmother to prevent my milk from coming in."
Answer: 4 Explanation: 4. A minimum of 6 to 10 wet diapers per day indicates adequate fluid intake.
The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching? 1. "Call your pediatrician if the baby's temperature is below 98.6°F axillary." 2. "Your baby's stools will change to a greenish color when your milk comes in." 3. "You can wipe away any eye drainage that might form." 4. "Your infant should wet a diaper at least 6 times per day."
Answer: 4 Explanation: 4. Another situation that can facilitate attachment is the interactive bath. While bathing their newborn for the first time, parents attend closely to their baby's behavior and the nurse can observe and point out behaviors.
The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? 1. "I should avoid looking directly into the baby's eyes to prevent frightening the baby." 2. "My baby will be very sleepy immediately after birth and should go to the nursery." 3. "Newborns cannot focus their eyes, so it doesn't matter how I hold my new baby." 4. "Giving the baby his first bath can really give me a chance to get to know him."
Answer: 1 Explanation: 1. Maintenance of temperature is an important aspect of phototherapy because the newborn is naked except for a diaper during phototherapy. The isolette helps the infant maintain his or her temperature while undressed.
The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? 1. The newborn maintains a normal temperature 2. An increase of serum bilirubin levels 3. Weight loss 4. Skin blanching yellow
Answer: 4 Explanation: 4. A client with hypertension is appropriate for labor induction.
The nurse is explaining induction of labor to a client. The client asks what the indications for labor induction are. Which of the following should the nurse include when answering the client? 1. Suspected placenta previa 2. Breech presentation 3. Prolapsed umbilical cord 4. Hypertension
Answer: 4 Explanation: 4. The ratio of whey to casein proteins in breast milk, unlike that in formula, is not static. It changes to meet the nutritional needs of the growing infant.
The nurse is explaining the nutritional differences between breast milk and formula to an expectant couple. The mother-to-be asks whether breast milk is nutritionally superior to formula. What should the nurse reply? 1. The vitamins and minerals in formula are more bioavailable to the infant. 2. There is no cholesterol in breast milk. 3. The only carbohydrate in breast milk is lactose. 4. The ratio of whey to casein proteins in breast milk changes to meet the nutritional needs of the growing infant.
Answer: 1 Explanation: 1. Pregnancies complicated by preeclampsia are high-risk situations. The woman with mild preeclampsia usually may have the analgesia or anesthesia of choice, although the incidence of hypotension with epidural anesthesia is increased. If hypotension occurs with the epidural block, it provides further stress on an already compromised cardiovascular system.
The nurse is inducing the labor of a client with severe preeclampsia. As labor progresses, fetal intolerance of labor develops. The induction medication is turned off, and the client is prepared for cesarean birth. Which statement should the nurse include in her preoperative teaching? 1. "Because of your preeclampsia you are at higher risk for hypotension after an epidural anesthesia." 2. "Because of your preeclampsia you might develop hypertension after a spinal anesthesia." 3. "Because of your preeclampsia your baby might have decreased blood pressure after birth." 4. "Because of your preeclampsia your husband will not be allowed into the operating room."
Answer: 3 Explanation: 3. The Plastibell should fall off within 8 days. If it remains on after 8 days, the parents should consult with the newborn's physician.
The nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within how long? 1. 2 days 2. 10 days 3. 8 days 4. 14 days
Answer: 1 Explanation: 1. Small, not large, amounts of uric acid crystals are normal in the first days of life.
The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern? 1. Large amounts of uric acid crystals in the first days of life 2. At least 6 to 10 wet diapers a day after the first few days of life 3. 1 to 2 stools a day for formula-fed baby 4. Urine that is straw to amber color without foul smell
Answer: 4 Explanation: 4. Newborns must go home from the birthing unit in a car seat adapted to fit newborns.
The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information? 1. "The baby should be in the back seat." 2. "Newborns must be in rear-facing car seats." 3. "We need instruction on how to use the car seat before installing it." 4. "We can bring the baby home from the hospital without a car seat as it is only a short drive home."
Answer: 2, 4, 5 Explanation: 2. Blood pressure should be monitored along with other vital signs. 4. The nurse should monitor contraction status (frequency, duration, intensity, resting tone, and associated maternal discomfort). 5. The nurse should continually check to make sure the infused fluid is being expelled from the vagina.
The nurse is monitoring a client who is receiving an amnioinfusion. Which assessments must the nurse perform to prevent a serious complication? Select all that apply. 1. Color of amniotic fluid 2. Maternal blood pressure 3. Cervical effacement 4. Uterine resting tone 5. Fluid leaking from the vagina
Answer: 1 Explanation: 1. This action is correct. Specific gravity provides one measure of urine concentration. Highly concentrated urine is associated with a dehydrated state. Weight loss is also a sign of developing dehydration in the newborn.
The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? 1. Urine specific gravity is assessed each voiding. 2. Eye coverings are left off to help keep the baby calm. 3. Temperature is checked every 6 hours. 4. The infant is taken out of the isolette for diaper changes.
Answer: 4 Explanation: 4. Unless delivery seems imminent because the client is bearing down or contractions are very close and strong, the vaginal exam is performed after the vital signs are obtained.
The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching has been effective? 1. "When a client arrives in labor, a urine specimen is obtained by catheter to check for protein and ketones." 2. "When a client arrives in labor, she will be positioned supine to facilitate a normal blood pressure." 3. "When a client arrives in labor, her prenatal record is reviewed for indications of domestic abuse." 4. "When a client arrives in labor, a vaginal exam is performed unless birth appears to be imminent."
Answer: 3 Explanation: 3. Gas Exchange, Impaired is related to immature pulmonary vasculature and inadequate surfactant production and has the highest priority.
The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority? 1. Tissue Integrity, Impaired 2. Infection, Risk for 3. Gas Exchange, Impaired 4. Family Processes, Dysfunctional
Answer: 2 Explanation: 2. Infants born to mothers with chlamydia infections are at risk for neonatal pneumonia and conjunctivitis, and require close observation of the respiratory status and eyes.
The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following? 1. A history of obsessive-compulsive disorder (OCD) 2. Chlamydia 3. Delivered six other children by cesarean section 4. A urinary tract infection (UTI)
Answer: 4 Explanation: 4. Oozing of greenish yellow material, or reddened areas around the cord is not an expected finding. This family should be seen first because the child is experiencing a complication.
The nurse is planning home visits to the homes of new parents and their newborns. Which client should the nurse see first? 1. 3-day-old male who received hepatitis B vaccine prior to discharge 2. 4-day-old female whose parents are both hearing-impaired 3. 5-day-old male with light, sticky, yellow drainage on the circumcision site 4. 6-day-old female with greenish discharge from the umbilical cord site
Answer: 1 Explanation: 1. Although it is true that some cultures believe colostrum to be unhealthy, colostrum helps to protect the infant from disease and illness.
The nurse is preparing a class on breastfeeding for pregnant women in their first trimester. The women are from a variety of cultural backgrounds, and all speak English well. Which statement should the nurse include in this presentation? 1. "Although some cultures believe colostrum is not good for the baby, it provides protection from infections and helps the digestive system to function." 2. "Some women are uncomfortable with exposing their breasts to nurse their infant, but it really isn't a big deal. You will get used to it." 3. "No religion prescribes a feeding method, so you all can choose whatever method makes the most sense to you." 4. "In most cultures, it is culturally acceptable to speak about intimate matters in front of their families."
Answer: 3 Explanation: 3. Cervical change is the only factor that actually distinguishes false from true labor. The contractions of true labor produce progressive dilatation and effacement of the cervix. The contractions of false labor do not produce progressive cervical effacement and dilatation.
The nurse is preparing a client education handout on the differences between false labor and true labor. What information is most important for the nurse to include? 1. True labor contractions begin in the back and sweep toward the front. 2. False labor often feels like abdominal tightening, or "balling up." 3. True labor can be diagnosed only if cervical change occurs. 4. False labor contractions do not increase in intensity or duration.
Answer: 1 Explanation: 1. Amniocentesis has the potential for causing a spontaneous abortion.
The nurse is preparing a client for amniocentesis. Which statement would indicate that the client clearly understands the risks of an amniocentesis? 1. "I might go into labor early." 2. "It could produce a congenital defect in my baby." 3. "Actually, there are no real risks to this procedure." 4. "The test could stunt my baby's growth."
Answer: 3 Explanation: 3. Three-dimensional ultrasound uses algorithms to vary opacity, transparency, and depth to project an image. This allows curved structures such as the fetal face to be viewed.
The nurse is preparing a client in her second trimester for a three-dimensional ultrasound examination. Which statement indicates that teaching has been effective? 1. "If the ultrasound is normal, it means my baby has no abnormalities." 2. "The nuchal translucency measurement will diagnose Down syndrome." 3. "I might be able to see who the baby looks like with the ultrasound." 4. "Measuring the length of my cervix will determine whether I will deliver early."
Answer: 1, 5 Explanation: 1. Physiologic or neonatal jaundice is a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life. 5. Kernicterus refers to the deposition of unconjugated bilirubin in the basal ganglia of the brain and to permanent neurologic sequelae of untreated hyperbilirubinemia.
The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? Select all that apply. 1. Physiologic jaundice occurs after 24 hours of age. 2. Pathologic jaundice occurs after 24 hours of age. 3. Phototherapy increases serum bilirubin levels. 4. The need for phototherapy depends on the bilirubin level and age of the infant. 5. Kernicterus causes irreversible neurological damage.
Answer: 2 Explanation: 2. PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein sources. Excessive accumulation of phenylalanine and its abnormal metabolites in the brain tissue leads to progressive, irreversible intellectual disability.
The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parent indicates that teaching was effective? 1. "This condition occurs more frequently among Japanese people." 2. "We must be very careful to avoid most proteins to prevent brain damage." 3. "Carbohydrates can cause our baby to develop cataracts and liver damage." 4. "Our baby's thyroid gland isn't functioning properly."
Answer: 1, 3, 4, 5 Explanation: 1. 0.5 to 1 mg is the correct dosage for vitamin K. 3. 25-gauge, 5/8-inch needle is the right size needle to use. 4. Vitamin K must be kept away from light. 5. A prophylactic injection of vitamin K1 is given to prevent hemorrhage, which can occur because of low prothrombin levels in the first few days of life.
The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate? Select all that apply. 1. Administer a dose of 0.5 to 1 mg within 1 hour of birth. 2. Administer the injection subcutaneously. 3. Use a 25-gauge, 5/8-inch needle for the injection. 4. Protect the medication bottle from light. 5. Give vitamin K prior to a circumcision procedure.
Answer: 1, 3, 4, 5 Explanation: 1. More than one episode of forceful vomiting or frequent vomiting over a 6-hour period should be reported to the healthcare provider. 3. Cyanosis (bluish discoloration of skin) with or without a feeding is a cause for concern, and should be reported to the healthcare provider immediately. 4. Refusal of two feedings in a row should be reported to the healthcare provider. 5. The infant should not have eye drainage after discharge and this condition should be reported to the healthcare provider.
The nurse is providing discharge teaching to the parents of a newborn. The nurse should instruct the parents to notify the healthcare provider in case of which of the following? Select all that apply. 1. More than one episode of forceful vomiting. 2. More than 6 to 10 wet diapers per day. 3. A bluish discoloration of the skin with or without a feeding. 4. Refusal of two feedings in a row. 5. Development of eye drainage.
Answer: 3 Explanation: 3. General anesthesia provides no pain relief after birth, as regional anesthesia does.
The nurse is providing preoperative teaching to a client for whom a cesarean birth under general anesthesia is scheduled for the next day. Which statement by the client indicates that she requires additional information? 1. "General anesthesia can be accomplished with inhaled gases." 2. "General anesthesia usually involves administering medication into my IV." 3. "General anesthesia will provide good pain relief after the birth." 4. "General anesthesia takes effect faster than an epidural."
Answer: 1 Explanation: 1. Lack of fetal movement can be an indication of nonreassuring fetal status or even fetal death. This client is the highest priority.
The nurse is responding to phone calls. Whose call should the nurse return first? 1. A client at 37 weeks' gestation reports no fetal movement for 24 hours. 2. A client at 29 weeks' gestation reports increased fetal movement. 3. A client at 32 weeks' gestation reports decreased fetal movement X 2 days. 4. A client at 35 weeks' gestation reports decreased fetal movement X 4 hours.
Answer: 4 Explanation: 4. A previous history of twins is not a risk factor for ectopic pregnancy. Beta hCG testing is not indicated for this client.
The nurse is returning phone calls from clients. Which client does the nurse anticipate would not require a serum beta hCG? 1. A client with a risk of ectopic pregnancy 2. A client with spotting during pregnancy 3. A client with previous pelvic inflammatory disease 4. A client with a previous history of twins
Answer: 2 Explanation: 2. 20 to 30 minutes of fetal monitoring is performed after the amniocentesis.
The nurse is reviewing amniocentesis results. Which of the following would indicate that client care was appropriate? 1. The client who is Rh-positive received Rh immune globulin after the amniocentesis. 2. The client was monitored for 30 minutes after completion of the test. 3. The client began vaginal spotting before leaving for home after the test. 4. The client identified that she takes insulin before each meal and at bedtime.
Answer: 1 Explanation: 1. Repeat cesarean births are associated with greater risks including increased incidence of abnormal placentation in subsequent pregnancies and the increased risk of mortality secondary to surgery, which would contribute to increased health care costs.
The nurse is reviewing charts of clients who underwent cesarean births by request in the last two years. The hospital is attempting to decrease costs of maternity care. What findings contribute to increased health care costs in clients undergoing cesarean birth by request? 1. Increased abnormal placenta implantation in subsequent pregnancies 2. Decreased use of general anesthesia with greater use of epidural anesthesia 3. Prolonged anemia, requiring blood transfusions every few months 4. Coordination of career projects of both partners leading to increased income
Answer: 1 Explanation: 1. Any previous uterine scar is a contraindication to ECV. Prior scarring of the uterus may increase the risk of uterine tearing or uterine rupture.
The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the client's chart requires immediate intervention? 1. Previous birth by cesarean 2. Frank breech ballotable 3. 37 weeks, complete breech 4. Failed ECV last week
Answer: 1, 2, 3, 5 Explanation: 1. Maternal hypotension results in decreased blood flow to the fetus. 2. Cord compression can cause fetal bradycardia. 3. This will cause fetal bradycardia if there is a fetal heart block. 5. This is a depression of myocardial activity.
The nurse is teaching a class on reading a fetal monitor to nursing students. The nurse explains that bradycardia is a fetal heart rate baseline below 110 and can be caused by which of the following? Select all that apply. 1. Maternal hypotension 2. Prolonged umbilical cord compression 3. Fetal dysrhythmia 4. Central nervous system malformation 5. Late fetal asphyxia
Answer: 1 Explanation: 1. Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in deciding whether VBAC is advisable. The classic vertical incision was commonly done in the past and is associated with increased risk of uterine rupture in subsequent pregnancies and labor.
The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which statement by a participant indicates that additional information is needed? 1. "Because the scar on my belly goes down from my navel, I am not a candidate for a VBAC." 2. "My first baby was in a breech position, so for this pregnancy, I can try a VBAC if the baby is head-down." 3. "Because my hospital is so small and in a rural area, they won't let me attempt a VBAC." 4. "The rate of complications from VBAC is lower than the rate of complications from a cesarean."
Answer: 2 Explanation: 2. Remove the baby's blanket and clothing so that the infant is wearing only a diaper and T-shirt. Babies feed better when they are not bundled, and they can achieve better attachment without the bulk of extra clothing and blankets. Swaddling the newborn has the opposite effect.
The nurse is teaching a new mother how to encourage a sleepy baby to breastfeed. Which of the following instructions would not be included in that teaching? 1. Providing skin-to-skin contact 2. Swaddling the newborn in a blanket 3. Unwrapping the newborn 4. Allowing the newborn to feel and smell the mother's breast
Answer: 1, 4 Explanation: 1. True labor contractions intensify while walking. 4. The discomfort of true labor contractions usually starts in the back and radiates around to the abdomen.
The nurse is teaching a prenatal class about false labor. The nurse should teach clients that false labor most likely will include which of the following? Select all that apply. 1. Contractions that do not intensify while walking 2. An increase in the intensity and frequency of contractions 3. Progressive cervical effacement and dilatation 4. Pain in the abdomen that does not radiate 5. Contractions are at regular intervals
Answer: 1 Explanation: 1. Exclusively breastfed infants have the same or slightly higher weight gain than their formula-fed and combination-fed peers in the first 3 to 4 months.
The nurse is teaching a prenatal class about feeding methods. A father-to-be asks the nurse which method, breast or formula, leads to the fastest infant growth and weight gain. Which response by the nurse is best? 1. "In the first 3 to 4 months breastfed babies tend to gain weight faster." 2. "In the first 3 to 4 months there is no difference in weight gain." 3. "In the first 3 to 4 months bottle-fed babies grow faster." 4. "In the first 3 to 4 months growth isn't as important as your comfort with the method."
Answer: 1, 3, 4 Explanation: 1. The nurse should instruct the parents on proper hand-washing technique. 3. The nurse should instruct parents to that soiled diapers are to be placed in plastic bags, sealed, and disposed of daily. 4. The nurse should instruct parents that the diaper-changing areas should be cleaned with a 1:10 dilution of household bleach after each diaper change.
The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for the newborn at home. Which instructions should the nurse emphasize? Select all that apply. 1. Use proper hand-washing technique. 2. Provide three feedings per day. 3. Place soiled diapers in a sealed plastic bag. 4. Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. 5. Take the temperature rectally.
Answer: 1 Explanation: 1. An afflicted PKU infant can be treated by a special diet that limits ingestion of phenylalanine. Special formulas low in phenylalanine, such as Lofenalac, Minafen, and Albumaid XP, are available.
The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. What information does teaching include? 1. Specially prepared formulas 2. Cataract problems 3. Low glucose concentrations 4. Administration of thyroid medication
Answer: 2 Explanation: 2. During the contraction, as the forceps are applied, the woman should avoid pushing.
The nurse is training a nurse new to the labor and delivery unit. They are caring for a laboring client who will have a forceps delivery. Which action or assessment finding requires intervention? 1. Regional anesthesia is administered via pudendal block. 2. The client is instructed to push between contractions. 3. Fetal heart tones are consistently between 110 and 115. 4. The client's bladder is emptied using a straight catheter.
Answer: 4 Explanation: 4. The preterm client with a history of preterm labor or cervical insufficiency needs close monitoring for preterm labor onset.
The nurse is working in an outpatient clinic. Which client's indications most warrant fetal monitoring in the third trimester? 1. Gravida 4, para 3, 39 weeks, with a history of one spontaneous abortion at 8 weeks 2. Gravida 1, para 0, 40 weeks, with a history of endometriosis and a prior appendectomy 3. Gravida 3, para 2, with a history of gestational diabetes controlled by diet 4. Gravida 2, para 1, 36 weeks, with a history of history of preterm labor or cervical insufficiency
Answer: 4 Explanation: 4. This response attempts to provide a compromise between acknowledging the client's desire to give formula and getting the baby to breast to get colostrum. Nurses should be aware that some immigrant mothers may have this misconception about their colostrum.
The nurse is working with a client from Southeast Asia. The client tells the nurse that she should not put the baby to breast until her milk comes in and her breasts are warm, because "cold milk" (colostrum) is bad for the baby. After the nurse explains the benefits of colostrum, the client still insists that "cold milk" is bad. Which response by the nurse is best? 1. "What kind of formula would you like to use?" 2. "That idea is folklore. Colostrum is good for the baby." 3. "Now that you are here, you need to feed your baby the right way." 4. "Let's give the baby formula after you breastfeed."
Answer: 2 Explanation: 2. Skin-to-skin contact after birth helps the baby maintain his or her body temperature, helps with self-regulation, increases maternal oxytocin levels, helps the mother to notice subtle feeding cues, and promotes bonding.
The nurse is working with a new mother who delivered yesterday. The mother has chosen to breastfeed her infant. Which demonstration of skill is the best indicator that the client understands breastfeeding? 1. She puts the infant to breast when he is asleep to help wake him up. 2. She takes off her gown to achieve skin-to-skin contact. 3. She leans toward the infant so that he turns his head to access the nipple. 4. The infant is crying when he is brought to the breast.
Answer: 2 Explanation: 2. This statement best answers the question the client has asked.
The nurse is working with a pregnant adolescent. The client asks the nurse how the baby's condition is determined during labor. The nurse's best response is that during labor, the nurse will do which of the following? 1. Check the client's cervix by doing a pelvic exam every 2 hours. 2. Assess the fetus's heart rate with an electronic fetal monitor. 3. Look at the color and amount of bloody show that the client has. 4. Verify that the client's contractions are strong but not too close together.
Answer: 4 Explanation: 4. This response is best because bathing the newborn offers an excellent opportunity for teaching and welcoming parent involvement in the care of their baby.
The nurse is working with an adolescent parent. The adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." What is the best response by the nurse? 1. "You are very young, and parenting will be a challenge for you." 2. "Your mother was probably right. Be very careful with your baby." 3. "Mothers have instincts that kick in when they get their babies home." 4. "We can give the baby's bath together. I'll help you learn how to do it."
Answer: 4 Explanation: 4. The nurse must be sensitive to the cultural beliefs and values of the family and be aware of cultural variations in newborn care.
The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn? 1. "You appear to be Muslim. Do you want your son circumcised?" 2. "Let me explain newborn care here in the United States." 3. "Your baby is a United States citizen. You must be very happy about that." 4. "Could you explain your preferences regarding childrearing?"
Answer: 3, 4, 5 Explanation: 3. Preterm infants grow more slowly than do term infants because of difficulty in meeting high caloric and fluid needs for growth due to small gastric capacity. 4. Although tube feedings might be required, it would be because preterm babies have a marked danger of aspiration and its associated complications due to the infant's poorly developed gag reflex, incompetent esophageal cardiac sphincter, and inadequate suck/swallow/breathe reflex. 5. Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they can produce urine. Preterm infants usually have some urine output during the first 24 hours of life.
The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statements by the parents indicate that additional teaching is needed? Select all that apply. 1. "Our baby will be in an incubator to keep him warm." 2. "Breathing might be harder for our baby because he is early." 3. "The growth of our baby will be faster than if he were term." 4. "Tube feedings will be required because his stomach is small." 5. "Because he came early, he will not produce urine for 2 days."
Answer: 1 Explanation: 1. Placenta previa is a contraindication to the induction of labor.
The nurse knows that a contraindication to the induction of labor is which of the following? 1. Placenta previa 2. Isoimmunization 3. Diabetes mellitus 4. Premature rupture of membranes
Answer: 3 Explanation: 3. The concentration of lecithin begins to exceed that of sphingomyelin, and at 35 weeks the L/S ratio is 2:1. When at least two times as much lecithin as sphingomyelin is found in the amniotic fluid, RDS is very unlikely.
The nurse knows that a lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid means which of the following? 1. Fetal lungs are still immature. 2. The fetus has a congenital anomaly. 3. Fetal lungs are mature. 4. The fetus is small for gestational age.
Answer: 3 Explanation: 3. Women with HIV or AIDS are counseled against breastfeeding.
The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding? 1. A mother with a poorly balanced diet 2. A mother who is overweight 3. A mother who is HIV positive 4. A mother who has twins
Answer: 1, 4, 5 Explanation: 1. Fetal station is one of the components evaluated by the Bishop scoring system. 4. Cervical effacement is one of the components evaluated by the Bishop scoring system. 5. Cervical consistency is one of the components evaluated by the Bishop scoring system.
The nurse knows that the Bishop scoring system for cervical readiness includes which of the following? Select all that apply. 1. Fetal station 2. Fetal lie 3. Fetal presenting part 4. Cervical effacement 5. Cervical softness
Answer: 2, 3, 4 Explanation: 2. One of advantages of spinal block is the relative ease of administration. 3. One of the advantages of spinal block is the maternal compartmentalization of the drug. 4. One of the advantages of spinal block is the immediate onset of anesthesia.
The nurse knows that which of the following are advantages of spinal block? Select all that apply. 1. Intense blockade of sympathetic fibers 2. Relative ease of administration 3. Maternal compartmentalization of the drug 4. Immediate onset of anesthesia 5. Larger drug volume
Answer: 2 Explanation: 2. Neonatal hyperbilirubinemia must be considered pathologic if the serum bilirubin concentration is rising by more than 0.2 mg/dL per hour. If the newborn is over 24 hours old, which is past the time where an increase in bilirubin would result from pathologic causes, phototherapy may be the treatment of choice to prevent the possible complications of kernicterus.
The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dL to 16.6 mg/dL in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn? 1. Continue to observe 2. Begin phototherapy 3. Begin blood exchange transfusion 4. Stop breastfeeding
Answer: 1, 3, 4, 5 Explanation: 1. Parents should call their healthcare provider due to a continual rise in temperature. 3. Parents should call their healthcare provider in the absence of breathing longer than 20 seconds. 4. Parents should call their healthcare provider if the newborn exhibits lethargy and listlessness. 5. Parents should call their healthcare provider if the newborn has refused of two feedings in a row.
The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs? Select all that apply. 1. Continual rise in temperature 2. Decreased frequency of stools 3. Absence of breathing longer than 20 seconds 4. Lethargy 5. Refusal of two feedings in a row
Answer: 3 Explanation: 3. If bleeding does occur, apply light pressure with a sterile gauze pad to stop the bleeding within a short time. If this is not effective, contact the physician immediately or take the newborn to the healthcare provider.
The nurse teaches the parents of an infant who recently was circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur? 1. Wrap the diaper tightly. 2. Clean with warm water with each diaper change. 3. Apply gentle pressure to the site with gauze. 4. Apply a new petroleum ointment gauze dressing.
Answer: 1, 2, 4 Explanation: 1. Providing a pacifier is an accepted method of soothing during the circumcision. 2. Stroking the head is an accepted method of soothing during the circumcision. 4. Talking to the infant is an accepted method of soothing during the circumcision.
The nurse tells a mother that the doctor is preparing to circumcise her newborn. The mother expresses concern that the infant will be uncomfortable during the procedure. The nurse explains that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure include which of the following? Select all that apply. 1. Providing a pacifier 2. Stroking the head 3. Restraining both arms and legs 4. Talking to the infant 5. Giving the infant a sedative before the procedure
Answer: 4 Explanation: 4. This answer is best because it explains what the parents will see in terminology that they will understand. A trusting relationship is essential for collaborative efforts in caring for the infant. The nurse should respond therapeutically to relate to the parents on a one-to-one basis.
The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best? 1. "I'll bring you to your baby and then leave so you can have some privacy." 2. "Your baby is on a ventilator with 50% oxygen, and has an umbilical line." 3. "I am so sorry this has all happened. I know how stressful this can be." 4. "Your baby is working hard to breathe and lying quite still, and has an IV."
Answer: 1 Explanation: 1. Tetralogy of Fallot is a cyanotic heart defect that comprises four abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricle hypertrophy. The severity of symptoms depends on the degree of pulmonary stenosis, the size of the ventricular septal defect, and the degree to which the aorta overrides the septal defect.
The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents do not seem to understand the explanation given by the physician. What statement by the nurse is best? 1. "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." 2. "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder." 3. "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart." 4. "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal."
Answer: 3 Explanation: 3. Asking this question allows the nurse to determine what the parents' concerns are, then address them specifically.
The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse? 1. "Circumcision should be undertaken to prevent problems in the future." 2. "Circumcision might decrease the child's risk of developing a urinary tract infection." 3. "Circumcision can sometimes cause complications. What questions do you have?" 4. "Circumcision is painful, and should be avoided unless you are Jewish."
Answer: 3 Explanation: 3. The nurse always should encourage parents to visit and get to know their newborn, even in the NICU. Nurses foster the development of a safe, trusting environment by viewing the parents as essential caregivers, not as visitors or nuisances in the unit.
The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is which of the following? 1. "Your newborn likes to be touched." 2. "Stroking the newborn will help with stimulation." 3. "Visits must be scheduled between feedings." 4. "Your baby loves her pink blanket."
Answer: 2 Explanation: 2. Fetal conditions indicating the need for forceps include premature placental separation, prolapsed umbilical cord, and nonreassuring fetal status.
The physician has determined the need for forceps. The nurse should explain to the client that the use of forceps is indicated because of which of the following? 1. Her support person is exhausted 2. Premature placental separation 3. To shorten the first stage of labor 4. To prevent fetal distress
Answer: 2 Explanation: 2. If more than three "pop-offs" occur (the suction cup pops off the fetal head), the procedure should be discontinued.
The physicians/CNM opts to use a vacuum extractor for a delivery. What does the nurse understand? 1. There is little risk with vacuum extraction devices. 2. There should be further fetal descent with the first two "pop-offs." 3. Traction is applied between contractions. 4. The woman often feels increased discomfort during the procedure.
Answer: 1 Explanation: 1. Amniocentesis results take longer to process than do CVS results.
The pregnant client and her partner are both 40 years old. The nurse is explaining the options of chorionic villus sampling (CVS) and amniocentesis for genetic testing. The nurse should correct the client if she makes which statement? 1. "Amniocentesis results are available sooner than CVS results are." 2. "CVS carries a higher risk of limb abnormalities." 3. "Amniocentesis cannot detect a neural tube defect." 4. "CVS is performed through my belly or my cervix."
Answer: 1 Explanation: 1. The term postmaturity applies to the infant who is born after 42 completed weeks of gestation and demonstrates characteristics of postmaturity syndrome.
The pregnant client at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best? 1. "Babies can develop post-maturity syndrome, which increases their chances of having complications after birth." 2. "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." 3. "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." 4. "The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger."
Answer: 1 Explanation: 1. A decrease in fetal cardiac output or an increase in resistance of placental vessels will reduce umbilical artery blood flow. Doppler velocimetry is best used when intrauterine growth restriction is diagnosed; therefore, the baby is getting an adequate blood supply.
The prenatal clinic nurse is explaining test results to a client who has had an assessment for fetal well-being. Which statement indicates that the client understands the test result? 1. "The normal Doppler velocimetry wave result indicates my placenta is getting enough blood to the baby." 2. "The reactive non-stress test means that my baby is not growing because of a lack of oxygen." 3. "Because my contraction stress test was positive, we know that my baby will tolerate labor well." 4. "My biophysical profile score of 6 points to everything being normal and healthy for my baby."
Explanation: 2. The fetal heart rate should accelerate with stimulation. 5. There will be some reaction with the stimulation.
The primary care provider is performing a fetal scalp stimulation test. What result would the nurse hope to observe? Select all that apply. 1. Spontaneous fetal movement 2. Fetal heart acceleration 3. Increase in fetal heart variability 4. Resolution of late decelerations 5. Reactivity associated with the stimulation Answer: 2, 5
Answer: 2, 5 Explanation: 2. Maternal hypotension results in uteroplacental insufficiency in the fetus, which is manifested as late decelerations on the fetal monitoring strip. 5. This would be a contraindication, as a narcotic can lower the blood pressure even more.
The primary physician orders a narcotic analgesic for a client in labor. Which situations would lead the nurse to hold the medication? Select all that apply. 1. Contraction pattern every 3 minutes for 60 seconds 2. Fetal monitor tracing showing late decelerations 3. Client sleeping between contractions 4. Blood pressure 150/90 5. Blood pressure 80/42
Answer: 2 Explanation: 2. A sick infant is a source of great anxiety for parents. This response is from the mother would be unexpected.
The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected? 1. "If I had taken better care of myself, this wouldn't have happened." 2. "I've been sleeping very well since I had the baby." 3. "This is probably the doctor's fault." 4. "If I hadn't seen our baby's birth, I wouldn't believe she is ours."
Delivery of neonate --> delivery of placenta
Third Stage: Beginning to end?
5-30 min
Third Stage: How long?
Answer: 1 Explanation: 1. The duration of each contraction is measured from the beginning of the contraction to the completion of the contraction.
To identify the duration of a contraction, the nurse would do which of the following? 1. Start timing from the beginning of one contraction to the completion of the same contraction. 2. Time between the beginning of one contraction and the beginning of the next contraction. 3. Palpate for the strength of the contraction at its peak. 4. Time from the beginning of the contraction to the peak of the same contraction.
Answer: 1, 2, 5 Explanation: 1. To maintain a healthy temperature in the newborn, keep the newborn's clothing and bedding dry. 2. To maintain a healthy temperature in the newborn, reduce the newborn's exposure to drafts. 5. To maintain a healthy temperature in the newborn, encourage the mother to snuggle with the newborn under blankets.
To maintain a healthy temperature in the newborn, which of the following actions should be taken? Select all that apply. 1. Keep the newborn's clothing and bedding dry. 2. Reduce the newborn's exposure to drafts. 3. Do not use the radiant warmer during procedures. 4. Do not wrap the newborn. 5. Encourage the mother to snuggle with the newborn under blankets.
Answer: 2 Explanation: 2. Parent should be instructed to allow only people with proper birthing unit identification to remove the baby from the room. If parents do not know the staff person, they should call the nurse for assistance.
To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following? 1. Keep the baby in the room at all times. 2. Check the identification of all personnel who transport the newborn. 3. Place a "No Visitors" sign on the door. 4. Keep the baby in the nursery at all times.
Answer: 1 Explanation: 1. Antacids are routinely administered before surgery for a cesarean section.
To reduce possible side effects from a cesarean section under general anesthesia, clients are routinely given which type of medication? 1. Antacids 2. Tranquilizers 3. Antihypertensives 4. Anticonvulsants
Answer: 4 Explanation: 4. Because a pudendal block is done using a local anesthetic, there is no need for additional monitoring of the mother or the fetus.
Toward the end of the first stage of labor, a pudendal block is administered transvaginally. What will the nurse anticipate the client's care will include? 1. Monitoring for hypotension every 15 minutes 2. Monitoring FHR every 15 minutes 3. Monitoring for bladder distention 4. No additional assessments
Answer: 2, 3, 4 Explanation: 2. A reason to remove prostaglandin from a client's cervix is the presence of nausea and vomiting. 3. A reason to remove prostaglandin from a client's cervix is uterine tachysystole. 4. A reason to remove prostaglandin from a client's cervix is cardiac tachysystole.
Under which circumstances would the nurse remove prostaglandin from the client's cervix? Select all that apply. 1. Contractions every 5 minutes 2. Nausea and vomiting 3. Uterine tachysystole 4. Cardiac tachysystole 5. Baseline fetal heart rate of 140-148
Answer: 1, 2, 3, 5 Explanation: 1. Early fetal hypoxia can cause fetal tachycardia. 2. Prolonged fetal stimulation can cause fetal tachycardia. 3. Fetal anemia can cause fetal tachycardia. 5. Infection can cause fetal tachycardia.
Upon assessing the FHR tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following? Select all that apply. 1. Early fetalhypoxia 2. Prolonged fetal stimulation 3. Fetal anemia 4. Fetal sleep cycle 5. Infection
Answer: 1, 3, 4, 5 Explanation: 1. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when the membranes rupture. 3. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when there is decreased fetal movement. 4. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when there is any vaginal bleeding. 5. The family is advised to arrive at the birth setting at the beginning of the active phase of labor or when there are regular, frequent uterine contractions.
Usually, the family is advised to arrive at the birth setting at the beginning of the active phase of labor or when which of the following occur? Select all that apply. 1. Rupture of membranes (ROM) 2. Increased fetal movement 3. Decreased fetal movement 4. Any vaginal bleeding 5. Regular, frequent uterine contractions (UCs)
Answer: 1, 2, 3 Explanation: 1. Formula composition does not vary unless the instructions for preparation and dilution are not followed. 2. Bacteria can be introduced if bottles and nipples are not properly cleaned. 3. If a mother has chosen not to breastfeed, then the father can be involved with bottle feedings from the start.
What are some of the advantages and disadvantages of formula-feeding that a nurse should discuss with new parents? Select all that apply. 1. The nutritional value of formula depends on the proper preparation/dilution. 2. There is a potential for bacterial contamination during preparation and storage. 3. Both parents can participate in positive parent-infant interaction during feeding. 4. Refrigeration is not necessary if preparing more than one bottle at a time. 5. Formula has higher levels of essential fatty acids, lactose, cystine, and cholesterol than does breast milk.
Answer: 1, 2, 3, 4 Explanation: 1. The nurse should provide information on maternal and infant nutrition, fluid requirements, and feeding methods. 2. The nurse should provide information that is accurate and consistent. Nurses have a responsibility to educate parents. 3. Every interaction is a chance to educate and support the new parents in learning how to care for the newborn. Nurses have a responsibility to educate parents. 4. It is important that parents receive verbal and written instructions and community resource information to which they can later refer.
What are the nurse's responsibilities when teaching the new mother about infant feeding? Select all that apply. 1. The nurse should be well informed about infant nutrition and feeding methods. 2. The nurse should provide accurate and consistent information. 3. The nurse should use each interaction to support the parents and promote the family's sense of confidence. 4. The nurse should familiarize the mother with information about community resources that might be helpful after discharge. 5. The nurse should aggressively promote breastfeeding, even if the parents have decided to bottle-feed their infant.
Answer: 2 Explanation: 2. Temperature instability is often seen with sepsis. Fever is rare in a newborn.
What indications would lead the nurse to suspect sepsis in a newborn? 1. Respiratory distress syndrome developing 48 hours after birth 2. Temperature of 97.0°F 2 hours after warming the infant from 97.4°F 3. Irritability and flushing of the skin at 8 hours of age 4. Bradycardia and tachypnea developing when the infant is 36 hours old
Answer: 1 Explanation: 1. Parents should be instructed to follow the directions on the formula can label precisely as written.
What information should the nurse include when teaching a new mother how to successfully bottle-feed her newborn? 1. Proper dilution of powdered formula is essential to provide adequate nutrition. 2. Keep formula at room temperature for at least 4 hours to warm it, instead of microwaving it. 3. Use enough water to dilute the nutrient and calorie density so the infant will drink more formula. 4. Freeze newly prepared formula for up to 3 months.
Answer: 1, 3, 4 Explanation: 1. Throughout the first 2 hours after birth, but especially during the first hour of life, most infants are usually alert and ready to breastfeed. 3. The new mother should be taught to recognize and respond to early infant feeding cues. The timing of newborn feedings is ideally determined by physiologic and behavioral cues rather than a set schedule. 4. It is important that parents receive verbal and written instructions and community resource information to which they can later refer.
What interventions would the nurse apply to support the breastfeeding mother? Select all that apply. 1. Assist the mother to begin breastfeeding within the first hour after birth. 2. Have the baby returned to the nursery after feeding so that the mother can get adequate rest. 3. Teach the mother to recognize and respond to early infant feeding cues. 4. Inform the mother about community resources that support breastfeeding. 5. Instruct the mother to avoid eating foods that might upset the newborn's stomach
Answer: 1 Explanation: 1. The major adverse effect of epidural anesthesia is maternal hypotension caused by a spinal blockade, which lowers peripheral resistance, decreases venous return to the heart, and subsequently lessens cardiac output and lowers blood pressure.
What is the major adverse side effect of epidural anesthesia? 1. Maternal hypotension 2. Decrease in variability of the FHR 3. Vertigo 4. Decreased or absent respiratory movements
Answer: 2 Explanation: 2. Lactose is the primary carbohydrate in mammalian milk.
What is the primary carbohydrate in mammalian milk that plays a crucial role in the nourishment of the newborn? 1. Colostrum 2. Lactose 3. Lactoferrin 4. Secretory IgA
Answer: 3, 4, 5 Explanation: 3. The healthcare provider should consider the drug's potential adverse effects to the infant. 4. The healthcare provider should consider the infant's age and health. 5. The healthcare provider should consider the mother's need for the medication.
What should the healthcare provider consider when prescribing a medication to a woman who is breastfeeding? Select all that apply. 1. Drug's potential effect on hormone production 2. Amount of drug excreted into the mother's blood 3. Drug's potential adverse effects to the infant 4. Infant's age and health 5. Mother's need for the medication
Fourth Stage
What stage of labor? Delivery of Placenta - Stabilization of Maternal VS 1-4 hr Lochia scant to moderate rubra
Third Stage
What stage of labor? Delivery of neonate - delivery of placenta 5-30 min Placental separation & expulsion
First Stage: Latent Phase
What stage of labor? Dilation: 0cm-3cm 6hr (P), 4hr (M) Contractions: irregular, mild-moderate Frequency: 5-30min Duration: 30-45 sec Some dilation & effacement Mother talkative & eager
First Stage: Active Phase
What stage of labor? Dilation: 4cm-7cm 3hr (P), 2hr (M) Contractions: more regular, moderate-strong Frequency: 3-5 mins Duration 40-70 sec Rapid dilation & effacement Some fetal descent Mother feels helpless Anxiety & restlessness as contractions become stronger
First Stage: Transition Phase
What stage of labor? Dilation: 8cm-10cm 20-40 min Contractions: strong-very strong Frequency: 2-3 min Duration 45-90 sec Mother tired, restless, irritable, feeling out of control, often states she cannot continue, urge to push, increased rectal pressure, feels need to have BM, increased bloody show Most difficult part of labor
Second Stage
What stage of labor? Full dilation - birth 30min-2hr (P), 5-30min (M) Contractions: intense Every 1-2 mins Pushing results in birth of fetus
First Stage
What stage of labor? Onset of labor till Complete dilation >12.5 hr Cervical dilation: 1cm/hr (P), 1.5 cm/hr (M)
Answer: 2 Explanation: 2. Piper forceps are designed to be used with a breech presentation. They are applied after the birth of the body, when the fetal head is still in the birth canal and assistance is needed.
What type of forceps are designed to be used with a breech presentation? 1. Midforceps 2. Piper 3. Low 4. High
Answer: 3 Explanation: 3. Clients are placed in a supine position on the table.
When assisting with a transabdominal sampling, which of the following would the nurse do? 1. Obtain preliminary urinary samples. 2. Have the woman empty her bladder before the test begins. 3. Assist the woman into a supine position on the examining table. 4. Instruct the woman to eat a fat-free meal 2 hours before the scheduled test time.
Answer: 4 Explanation: 4. The anterior and posterior fontanelles are clinically useful in identifying the position of the fetal head in the pelvis and in assessing the status of the newborn after birth.
When comparing the anterior and posterior fontanelles of a newborn, the nurse knows that both are what? 1. Both are approximately the same size 2. Both close within 12 months of birth 3. Both are used in labor to identify station 4. Both allow for assessing the status of the newborn after birth
Answer: 1, 3, 4, 5 Explanation: 1. Prophylactic antacid therapy is given to reduce the acidic content of the stomach before general anesthesia. 3. During the process of rapid induction of anesthesia, the nurse applies cricoid pressure. 4. The woman should be preoxygenated with 3 to 5 minutes of 100% oxygen. 5. Urinary retention can be treated with the placement of an indwelling Foley catheter.
When general anesthesia is necessary for a cesarean delivery, what should the nurse be prepared to do? Select all that apply. 1. Administer an antacid to the client. 2. Place a wedge under her thigh. 3. Apply cricoid pressure during anesthesia intubation. 4. Preoxygenate for 3-5 minutes before anesthesia. 5. Place a Foley catheter in the client's bladder.
Answer: 1, 3, 4, 5 Explanation: 1. The physiologic alterations of RDS can produce hypoxia as a complication. As a result of hypoxia, the pulmonary vasculature constricts, pulmonary vascular resistance increases, and pulmonary blood flow is reduced. 3. The physiologic alterations of RDS can produce metabolic acidosis as a complication. Because cells lack oxygen, the newborn begins an anaerobic pathway of metabolism, with an increase in lactate levels and a resulting base deficit. 4. The physiologic alterations of RDS can produce massive atelectasis as a complication. Upon expiration, the instability increases the atelectasis, which causes hypoxia and acidosis because of the lack of gas exchange. 5. The physiologic alterations of RDS can produce pulmonary edema as a complication. Opacification of the lungs on X-ray image may be due to massive atelectasis, diffuse alveolar infiltrate, or pulmonary edema.
When planning care for the premature newborn diagnosed with respiratory distress syndrome, which potential complications would the nurse anticipate? Select all that apply. 1. Hypoxia 2. Respiratory alkalosis 3. Metabolic acidosis 4. Massive atelectasis 5. Pulmonary edema
Answer: 1, 2, 3, 4 Explanation: 1. Multiparous mothers produce milk with a lower content of fatty acids than primigravidas. 2. The milk of a mother who delivers a preterm infant has a greater concentration of DHA and ARA than does the milk of a mother who gives birth to a full-term infant. 3. Phospholipids and cholesterol levels are higher in colostrum than in mature milk, although overall fat content is higher in mature breast milk than in colostrum. 4. Fat content is generally higher in the evening and lower in the early morning.
When teaching the new mother about the composition of breast milk, the nurse explains that the fat content can range from 30 to 50 grams/liter. Which factors affect the fat content of breast milk? Select all that apply. 1. Maternal parity 2. Duration of pregnancy 3. Stage of lactation 4. Time of day 5. Vitamin C intake
Answer: 1 Explanation: 1. Jitteriness of the newborn is associated with hypoglycemia. Aggressive treatment is recommended after a single low blood glucose value if the infant shows this symptom.
Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn? 1. Jitteriness 2. Sucking on fingers 3. Lusty cry 4. Axillary temperature of 98°F
Answer: 1, 3, 4, 5 Explanation: 1. Central cyanosis is defined as a visible, blue discoloration of the skin caused by decreased oxygen saturation levels and is a common manifestation of a cardiac defect. 3. The signs of congestive heart failure include tachycardia, not bradycardia. 4. The signs of congestive heart failure include low urinary output. 5. The signs of congestive heart failure include tachypnea.
Which assessment findings would lead the nurse to suspect that a newborn might have a congenital heart defect? Select all that apply. 1. Cyanosis 2. Heart murmur 3. Bradycardia 4. Low urinary outputs 5. Tachypnea
Answer: 2 Explanation: 2. The white blood cell (WBC) count increases to 25,000/mm3 to 30,000/mm3 during labor and early postpartum. This count is abnormally high, and requires further assessment and provider notification.
Which client requires immediate intervention by the labor and delivery nurse? 1. Client at 8 cm, systolic blood pressure has increased 35 mm Hg 2. Client who delivered 1 hour ago with WBC of 50,000 3. Client at 5 cm with a respiratory rate of 22 between contractions 4. Client in active labor with polyuria
Answer: 1, 3, 4, 5 Explanation: 1. Nonreassuring fetal heart rate pattern/sustained bradycardia would be considered a potential need to resuscitate a newborn. 3. History of meconium in amniotic fluid would be considered a potential need to resuscitate a newborn. 4. Prematurity would be considered a potential need to resuscitate a newborn. 5. Significant intrapartum bleeding would be considered a potential need to resuscitate a newborn.
Which fetal/neonatal risk factors would lead the nurse to anticipate a potential need to resuscitate a newborn? Select all that apply. 1. Nonreassuring fetal heart rate pattern/sustained bradycardia 2. Fetal scalp/capillary blood sample pH greater than 7.25 3. History of meconium in amniotic fluid 4. Prematurity 5. Significant intrapartum bleeding
Answer: 1, 2, 3 Explanation: 1. Rhinitis is evident in the newborn exposed to syphilis. 2. Fissures on mouth corners and an excoriated upper lip indicate exposure to syphilis. 3. A red rash around the mouth and anus is observed.
Which findings would the nurse expect when assessing a newborn infected with syphilis? Select all that apply. 1. Rhinitis 2. Fissures on mouth corners 3. Red rash around anus 4. Lethargy 5. Large for gestational age
Answer: 2, 3, 4 Explanation: 2. Folding the diaper down to prevent coverage of the cord stump can prevent contamination of the area and promote drying. 3. Keeping the umbilical stump clean and dry can reduce the risk of infection. 4. It is the nurse's responsibility to instruct parents in caring for the cord and observing for signs and symptoms of infection after discharge, such as foul smell, redness and greenish yellow drainage, localized heat and tenderness, or bright red bleeding or if the area remains unhealed 2 to 3 days after the cord has sloughed off.
Which instructions should the nurse include when teaching parents of a newborn about caring for the umbilical cord? Select all that apply. 1. Use triple-dye to cleanse the umbilical cord at home. 2. Fold the diaper down to prevent covering the cord stump. 3. Keep the umbilical stump clean and dry to avoid infection. 4. Observe for signs of infection such as foul smell, redness, and drainage. 5. Begin tub baths to help cleanse the cord stump at home.
Answer: 4, 5 Explanation: 4. The nurse should initiate efforts to block heat loss by evaporation, radiation, convection, and conduction. 5. The infant should be warmed slowly to prevent hypotension and apnea.
Which nursing intervention is appropriate in the management of the preterm infant with hypothermia? Select all that apply. 1. Warm the baby rapidly to reverse the hypothermia. 2. Monitor skin temperature every 2 hours to determine whether the infant's temperature is increasing. 3. Keep IV fluids at room temperature. 4. Initiate efforts to maintain the newborn in a neutral thermal environment. 5. Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment.
Answer: 2, 3, 5 Explanation: 2. Apply eye patches over the newborn's closed eyes during exposure to banks of phototherapy. 3. Discontinue conventional phototherapy and remove the eye patches at least once per shift to assess the eyes for the presence of conjunctivitis. 5. Repositioning allows equal exposure of all skin areas and prevents pressure areas.
Which nursing interventions are appropriate when caring for the newborn undergoing phototherapy? Select all that apply. 1. Cover the newborn's eyes at all times, even when not under the lights. 2. Close the newborn's eyelids before applying eye patches. 3. Inspect the eyes each shift for conjunctivitis. 4. Keep the baby swaddled in a blanket to prevent heat loss. 5. Reposition the baby every 2 hours.
Answer: 1, 2, 5 Explanation: 1. The nurse can be an excellent role model for families. Teaching by example is a very effective way to teach infant care. 2. One-to-one teaching while the nurse is in the client's room is shown to be the most effective educational model. 5. One-to-one teaching while the nurse is in the client's room is the most effective educational model.
Which of the following activities allows the nurse to provide individualized parent teaching on the maternal-infant unit? Select all that apply. 1. Teach by example and role modeling when caring for the newborn in the client's room. 2. Teach at every opportunity, even during the night shift, if the occasion arises. 3. Teach using newborn care videos and group classes. 4. Teach using the 24-hour educational television channels in the client's room. 5. Teach using one-to-one instruction while in the client's room.
Answer: 2, 4, 5 Explanation: 2. Previous sibling received phototherapy is considered a risk factor for development of severe hyperbilirubinemia. 4. Exclusive breastfeeding, particularly if nursing is not going well and excessive weight loss is experienced, is considered a risk factor for development of severe hyperbilirubinemia. 5. Infection is considered a risk factor for development of severe hyperbilirubinemia.
Which of the following are considered risk factors for development of severe hyperbilirubinemia? Select all that apply. 1. Northern European descent 2. Previous sibling received phototherapy 3. Gestational age 27 to 30 weeks 4. Exclusive breastfeeding 5. Infection
Answer: 1, 2, 5 Explanation: 1. Nipple tenderness is the most common source of discomfort and is usually related to improper positioning and/or not obtaining a proper attachment of the infant on the breast. Pain can also be related to engorgement or infection. 2. Some women will leak milk when their breasts are full and it is nearly time to breastfeed again or whenever they experience let-down. Mothers should be given reassurance that this problem diminishes over time. 5. Some mothers feel uncomfortable about breastfeeding because they are modest or may feel embarrassed because our society views breasts as sexual objects and/or an unfriendly social environment makes it difficult to breastfeed in public. This is not an easy issue to overcome.
Which of the following are potential disadvantages to breastfeeding? Select all that apply. 1. Pain with breastfeeding 2. Leaking milk 3. Equal feeding responsibilities with fathers 4. Vaginal wetness 5. Embarrassment
Answer: 3 Explanation: 3. Feelings of dysphoria are a major side effect of Stardol.
Which of the following is a major side effect of butorphanol tartrate (Stadol)? 1. Blurred vision 2. Agitation 3. Feelings of dysphoria 4. Drowsiness
Answer: 4 Explanation: 4. Depressed fontanelles are a sign of dehydration in the newborn.
Which of the following is a sign of dehydration in the newborn? 1. Slow, weak pulse 2. Soft, loose stools 3. Light colored, concentrated urine 4. Depressed fontanelles
Answer: 3 Explanation: 3. The non-stress test (NST) has become a widely accepted method of evaluating fetal status. This test involves using an external electronic fetal monitor to obtain a tracing of the fetal heart rate (FHR) and observation of acceleration of the FHR with fetal movement.
Which of the following tests has become a widely accepted method of evaluating fetal status? 1. Contraction stress test (CST) 2. MSAFP test 3. Non-stress test (NST) 4. Nuchal translucency test
Answer: 2 Explanation: 2. A standard (comprehensive) second trimester sonogram provides the information about the fetus, placenta, and uterine conditions including fetal number.
Which of the following tests provides information about the fetal number? 1. Amniocentesis 2. Standard second-trimester sonogram 3. Beta hCG 4. Maternal serum alpha-fetoprotein
Answer: 1, 2, 5 Explanation: 1. Skin-to-skin contact after birth helps the baby maintain his or her body temperature, helps with self-regulation, increases maternal oxytocin levels, helps the mother to notice subtle feeding cues, and promotes bonding. 2. Hormones of lactation promote maternal feelings and sense of well-being. 5. This is a true statement. The immunologic advantages of human milk include varying degrees of protection from respiratory tract and gastrointestinal tract infections.
Which statements by a breastfeeding class participant indicate that teaching by the nurse was effective? Select all that apply. 1. "Breastfed infants get more skin-to-skin contact and sleep better." 2. "Breastfeeding raises the level of a hormone that makes me feel good." 3. "Breastfeeding is complex and difficult, and I probably won't succeed." 4. "Breastfeeding is worthwhile, even if it costs more overall." 5. "Breastfed infants have fewer digestive and respiratory illnesses."
Answer: 4 Explanation: 4. The fetus changes position in the following order: descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion.
While caring for a client in labor, the nurse notices during a vaginal exam that the fetus's head has rotated internally. What would the nurse expect the next set of cardinal movements for a fetus in a vertex presentation to be? 1. Flexion, extension, restitution, external rotation, and expulsion 2. Expulsion, external rotation, and restitution 3. Restitution, flexion, external rotation, and expulsion 4. Extension, restitution, external rotation, and expulsion
